Provider Demographics
NPI:1114174000
Name:NUTHAKKI, SOUJANYA (MD)
Entity Type:Individual
Prefix:
First Name:SOUJANYA
Middle Name:
Last Name:NUTHAKKI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1300 N PROSPECT AVE
Mailing Address - Street 2:APT 200
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-3022
Mailing Address - Country:US
Mailing Address - Phone:414-771-7470
Mailing Address - Fax:
Practice Address - Street 1:10400 W NORTH AVE STE 300
Practice Address - Street 2:
Practice Address - City:WAUWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53226-2425
Practice Address - Country:US
Practice Address - Phone:414-771-7470
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-21
Last Update Date:2008-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI52092207U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207U00000XAllopathic & Osteopathic PhysiciansNuclear Medicine