Provider Demographics
NPI:1649240417
Name:YALALA, SRIDEVI (MD)
Entity Type:Individual
Prefix:
First Name:SRIDEVI
Middle Name:
Last Name:YALALA
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 1:1985 W BIG BEAVER RD STE 310
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:MI
Mailing Address - Zip Code:48084-3409
Mailing Address - Country:US
Mailing Address - Phone:248-269-3412
Mailing Address - Fax:888-514-6288
Practice Address - Street 1:1985 W BIG BEAVER RD
Practice Address - Street 2:SUITE310
Practice Address - City:TROY
Practice Address - State:MI
Practice Address - Zip Code:48084-3421
Practice Address - Country:US
Practice Address - Phone:248-269-3412
Practice Address - Fax:888-514-6288
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-25
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301064391207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4470490Medicaid
MI4470490Medicaid