Provider Demographics
NPI:1376679514
Name:KAMBHATLA, SUJATA (MD)
Entity Type:Individual
Prefix:DR
First Name:SUJATA
Middle Name:
Last Name:KAMBHATLA
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 1:5823 MIDDLEBELT RD
Mailing Address - Street 2:
Mailing Address - City:GARDEN CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48135-2459
Mailing Address - Country:US
Mailing Address - Phone:734-421-6333
Mailing Address - Fax:
Practice Address - Street 1:5823 MIDDLEBELT RD
Practice Address - Street 2:
Practice Address - City:GARDEN CITY
Practice Address - State:MI
Practice Address - Zip Code:48135-2459
Practice Address - Country:US
Practice Address - Phone:734-421-6333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-24
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISK4301067805207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI110827980OtherBCBS
MIN20400001OtherMEDICARE RENDERRING ID
MI104565305Medicaid
MISK067805OtherLICENSE NUMBER
MI1891767281OtherORGANIZATIONAL NPI
MI383564379OtherTAX ID
MI0N20400Medicare ID - Type Unspecified
MI1891767281OtherORGANIZATIONAL NPI