Provider Demographics
NPI:1720267800
Name:KAKULAVARAM, AMITHA (MD)
Entity type:Individual
Prefix:
First Name:AMITHA
Middle Name:
Last Name:KAKULAVARAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:5280 METROPOLITAN PKWY
Mailing Address - Street 2:
Mailing Address - City:STERLING HEIGHTS
Mailing Address - State:MI
Mailing Address - Zip Code:48310-4005
Mailing Address - Country:US
Mailing Address - Phone:248-858-3011
Mailing Address - Fax:800-414-1646
Practice Address - Street 1:44200 WOODWARD AVE STE 209
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-5045
Practice Address - Country:US
Practice Address - Phone:248-253-0330
Practice Address - Fax:248-253-1982
Is Sole Proprietor?:No
Enumeration Date:2007-10-25
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301084121207RN0300X, 207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1720267800Medicaid