Basic Information
| Provider Information | |||||||||
| NPI: | 1629216007 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | NELLUTLA | ||||||||
| FirstName: | LAKSHMI | ||||||||
| MiddleName: | SUBBA | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17197 N LAUREL PARK DR | ||||||||
| Address2: | SUITE 161 | ||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481522680 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7343388300 | ||||||||
| FaxNumber: | 7343388301 | ||||||||
| Practice Location | |||||||||
| Address1: | 7733 E JEFFERSON AVE | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482143707 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3134994900 | ||||||||
| FaxNumber: | 3134994483 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/23/2009 | ||||||||
| LastUpdateDate: | 10/06/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 4301093294 | MI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 700H231390 | 01 | MI | BCBS GROUP NUMBER | OTHER |