Provider Demographics
NPI:1356070437
Name:KAKARLA, PAVAN
Entity Type:Individual
Prefix:
First Name:PAVAN
Middle Name:
Last Name:KAKARLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15716 STROH LN
Mailing Address - Street 2:
Mailing Address - City:SAINT MARYS
Mailing Address - State:OH
Mailing Address - Zip Code:45885-9256
Mailing Address - Country:US
Mailing Address - Phone:567-712-4378
Mailing Address - Fax:
Practice Address - Street 1:461 W HURON ST
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-1601
Practice Address - Country:US
Practice Address - Phone:248-857-7200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-06-06
Last Update Date:2022-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4351050300390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program