Provider Demographics
NPI:1194754036
Name:YEDAVALLY, SUNITA (DO)
Entity type:Individual
Prefix:DR
First Name:SUNITA
Middle Name:
Last Name:YEDAVALLY
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:39650 ORCHARD HILL PL
Mailing Address - Street 2:200
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48375-5331
Mailing Address - Country:US
Mailing Address - Phone:248-319-0161
Mailing Address - Fax:248-319-0170
Practice Address - Street 1:2000 N HURON RIVER DR
Practice Address - Street 2:100
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-1699
Practice Address - Country:US
Practice Address - Phone:734-572-1200
Practice Address - Fax:734-572-9760
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2022-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101009249207W00000X, 207WX0107X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
0C36078Medicare PIN
E70277Medicare UPIN
MI1194754036Medicaid
0Q26082031Medicare PIN
0Q26082031Medicare PIN
MI4157689Medicaid