Provider Demographics
NPI:1376823286
Name:KALLADI PUTHANPURAYIL, SHABANA (MD)
Entity Type:Individual
Prefix:
First Name:SHABANA
Middle Name:
Last Name:KALLADI PUTHANPURAYIL
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 1:130 TOWN CENTER DR STE 203
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-1744
Mailing Address - Country:US
Mailing Address - Phone:248-585-8250
Mailing Address - Fax:248-585-8270
Practice Address - Street 1:3535 W 13 MILE RD STE 707
Practice Address - Street 2:
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073-6770
Practice Address - Country:US
Practice Address - Phone:248-551-0487
Practice Address - Fax:248-551-3696
Is Sole Proprietor?:No
Enumeration Date:2011-08-23
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010978822080P0205X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics