Provider Demographics
NPI:1629216007
Name:NELLUTLA, LAKSHMI SUBBA (MD)
Entity Type:Individual
Prefix:DR
First Name:LAKSHMI
Middle Name:SUBBA
Last Name:NELLUTLA
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:17197 N LAUREL PARK DR
Mailing Address - Street 2:SUITE 161
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-2680
Mailing Address - Country:US
Mailing Address - Phone:734-338-8300
Mailing Address - Fax:734-338-8301
Practice Address - Street 1:7733 E JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48214-3707
Practice Address - Country:US
Practice Address - Phone:313-499-4900
Practice Address - Fax:313-499-4483
Is Sole Proprietor?:No
Enumeration Date:2009-01-23
Last Update Date:2010-10-06
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
MI4301093294207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700H231390OtherBCBS GROUP NUMBER
MI0P47270Medicare PIN