Provider Demographics
NPI:1023215886
Name:THATIKONDA, NARENDER REDDY (MD)
Entity Type:Individual
Prefix:DR
First Name:NARENDER
Middle Name:REDDY
Last Name:THATIKONDA
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 1:9900 W M 21 STE 101
Mailing Address - Street 2:
Mailing Address - City:OVID
Mailing Address - State:MI
Mailing Address - Zip Code:48866-9798
Mailing Address - Country:US
Mailing Address - Phone:989-834-2243
Mailing Address - Fax:989-834-5478
Practice Address - Street 1:9900 W M 21 STE 101
Practice Address - Street 2:
Practice Address - City:OVID
Practice Address - State:MI
Practice Address - Zip Code:48866-9798
Practice Address - Country:US
Practice Address - Phone:989-834-2243
Practice Address - Fax:989-834-5478
Is Sole Proprietor?:No
Enumeration Date:2007-06-27
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301104434207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1023215886Medicaid
MIN53550102Medicare PIN
LA1457621OtherMEDICAID RURAL GROUP
LA193870OtherMEDICARE RURAL GROUP
LA193875OtherMEDICARE RURAL GROUP
LA4K631CE42Medicare PIN