Provider Demographics
NPI:1336104470
Name:VANAHARAM, KAMALA J (MD)
Entity Type:Individual
Prefix:
First Name:KAMALA
Middle Name:J
Last Name:VANAHARAM
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 1:7828 22 MILES RD
Mailing Address - Street 2:
Mailing Address - City:UTICA
Mailing Address - State:MI
Mailing Address - Zip Code:48317
Mailing Address - Country:US
Mailing Address - Phone:586-254-8581
Mailing Address - Fax:586-254-5232
Practice Address - Street 1:7828 22 MILES RD
Practice Address - Street 2:
Practice Address - City:UTICA
Practice Address - State:MI
Practice Address - Zip Code:48317
Practice Address - Country:US
Practice Address - Phone:586-254-8581
Practice Address - Fax:586-254-5232
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-20
Last Update Date:2013-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301045820208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2125846Medicaid
MION71230Medicare ID - Type Unspecified
MI2125846Medicaid