Basic Information
Provider Information | |||||||||
NPI: | 1326298779 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TADAKAMALLA | ||||||||
FirstName: | ASHVIN | ||||||||
MiddleName: | KARTHIK | ||||||||
NamePrefix: | DR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 900 MARTIN LUTHER KING JR BLVD S | ||||||||
Address2: | #G129 FOX POINTE APARTMENTS | ||||||||
City: | PONTIAC | ||||||||
State: | MI | ||||||||
PostalCode: | 483412900 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6309451247 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 44405 WOODWARD AVE | ||||||||
Address2: |   | ||||||||
City: | PONTIAC | ||||||||
State: | MI | ||||||||
PostalCode: | 483415023 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2488583234 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 09/23/2008 | ||||||||
LastUpdateDate: | 07/20/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | 284882 | NY | Y |   | Allopathic & Osteopathic Physicians | Hospitalist |   | 208600000X | L1346413 | MI | N |   | Allopathic & Osteopathic Physicians | Surgery |   |
No ID Information.