Provider Demographics
NPI:1477040608
Name:KODALI, POOJA (MD)
Entity Type:Individual
Prefix:
First Name:POOJA
Middle Name:
Last Name:KODALI
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 1:16828 HORSESHOE DR
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48168-8586
Mailing Address - Country:US
Mailing Address - Phone:248-277-8703
Mailing Address - Fax:
Practice Address - Street 1:16226 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48227-1824
Practice Address - Country:US
Practice Address - Phone:313-836-5491
Practice Address - Fax:313-836-5224
Is Sole Proprietor?:No
Enumeration Date:2018-04-13
Last Update Date:2024-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301511158207Q00000X
MI4351046203390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine