Provider Demographics
NPI:1013223239
Name:BATHULA, SAMBA SIVA REDDY (MD)
Entity Type:Individual
Prefix:DR
First Name:SAMBA SIVA REDDY
Middle Name:
Last Name:BATHULA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4160 JOHN R ST STE 1007
Mailing Address - Street 2:DMC ENT-HARPER PROFESSIONAL BUILDING
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2017
Mailing Address - Country:US
Mailing Address - Phone:313-966-9471
Mailing Address - Fax:313-966-9470
Practice Address - Street 1:4160 JOHN R ST STE 1007
Practice Address - Street 2:DMC ENT-HARPER PROFESSIONAL BUILDING
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2017
Practice Address - Country:US
Practice Address - Phone:313-966-9471
Practice Address - Fax:313-966-9470
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-25
Last Update Date:2015-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301096231207YP0228X, 207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No207YP0228XAllopathic & Osteopathic PhysiciansOtolaryngologyPediatric Otolaryngology