Provider Demographics
NPI:1154434975
Name:DATLA, SAILAJA (MD)
Entity type:Individual
Prefix:
First Name:SAILAJA
Middle Name:
Last Name:DATLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24800 HARPER AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:SAINT CLAIR SHORES
Mailing Address - State:MI
Mailing Address - Zip Code:48080-1292
Mailing Address - Country:US
Mailing Address - Phone:586-445-3706
Mailing Address - Fax:586-445-3709
Practice Address - Street 1:24800 HARPER AVE STE 1
Practice Address - Street 2:
Practice Address - City:SAINT CLAIR SHORES
Practice Address - State:MI
Practice Address - Zip Code:48080-1292
Practice Address - Country:US
Practice Address - Phone:586-445-3706
Practice Address - Fax:586-445-3709
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301070545207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
H14633Medicare UPIN
0N41150Medicare ID - Type Unspecified