Provider Demographics
NPI:1427147628
Name:JONNALAGADDA, SAMUEL DAVID (MD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:DAVID
Last Name:JONNALAGADDA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:SAMUEL
Other - Middle Name:DAVID
Other - Last Name:JONNALAGADDA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:8800 COMMERCE RD
Mailing Address - Street 2:
Mailing Address - City:COMMERCE TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48382-4413
Mailing Address - Country:US
Mailing Address - Phone:248-363-7500
Mailing Address - Fax:248-363-7700
Practice Address - Street 1:8800 COMMERCE RD
Practice Address - Street 2:
Practice Address - City:COMMERCE TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48382
Practice Address - Country:US
Practice Address - Phone:248-363-7500
Practice Address - Fax:248-363-7700
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2018-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301076908208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4614464-10Medicaid
MII00907Medicare UPIN