Provider Demographics
NPI:1326395948
Name:KAKKERALA, SUSHMA (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSHMA
Middle Name:
Last Name:KAKKERALA
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 1:4201 ST. ANTOINE
Mailing Address - Street 2:UHC 5D - MAILBOX 226
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2153
Mailing Address - Country:US
Mailing Address - Phone:313-966-5051
Mailing Address - Fax:313-966-0665
Practice Address - Street 1:3901 BEAUBIEN
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201
Practice Address - Country:US
Practice Address - Phone:313-966-0128
Practice Address - Fax:313-993-0390
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-14
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301501155208000000X
GA074206208000000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program