Provider Demographics
NPI:1417916818
Name:DOYLE, KALLI JO (MD)
Entity Type:Individual
Prefix:
First Name:KALLI JO
Middle Name:
Last Name:DOYLE
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 DRIVE
Mailing Address - Street 2:STE 203
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-1744
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3535 W 13 MILE RD STE LL
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:248-551-3000
Practice Address - Fax:248-551-2032
Is Sole Proprietor?:No
Enumeration Date:2006-03-23
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301406534208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1417916818Medicaid
MIF42070Medicare UPIN
MI1417916818Medicaid
MIF42070Medicare UPIN