Provider Demographics
NPI:1528015427
Name:KANNAN, LATHA THIRUCHELVAN (MD)
Entity Type:Individual
Prefix:
First Name:LATHA
Middle Name:THIRUCHELVAN
Last Name:KANNAN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LATHA
Other - Middle Name:THIRUCHELVAN
Other - Last Name:GANESAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:34687 PICKFORD DR
Mailing Address - Street 2:
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48335-2073
Mailing Address - Country:US
Mailing Address - Phone:248-980-6150
Mailing Address - Fax:248-353-4235
Practice Address - Street 1:22972 LAHSER RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48034-4408
Practice Address - Country:US
Practice Address - Phone:248-353-4777
Practice Address - Fax:248-353-4235
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301070401207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4646584Medicaid
MI4646584Medicaid
MIH71165Medicare UPIN