Provider Demographics
NPI:1295840734
Name:SUDHAKARA, KAJOOR (MD)
Entity Type:Individual
Prefix:DR
First Name:KAJOOR
Middle Name:
Last Name:SUDHAKARA
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 1:1675 KINGSWAY CT
Mailing Address - Street 2:
Mailing Address - City:TRENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48183-1958
Mailing Address - Country:US
Mailing Address - Phone:734-676-8530
Mailing Address - Fax:734-676-2319
Practice Address - Street 1:1675 KINGSWAY CT
Practice Address - Street 2:
Practice Address - City:TRENTON
Practice Address - State:MI
Practice Address - Zip Code:48183-1958
Practice Address - Country:US
Practice Address - Phone:734-676-8530
Practice Address - Fax:734-676-2319
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301060936207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3172321Medicaid
MIG13589Medicare UPIN
MI0M14200001Medicare ID - Type Unspecified