Provider Demographics
NPI:1689696106
Name:KONERU, PRAVEENA (MD)
Entity Type:Individual
Prefix:DR
First Name:PRAVEENA
Middle Name:
Last Name:KONERU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 77000 DEPT 771255 DEPT 771255
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48277-1255
Mailing Address - Country:US
Mailing Address - Phone:313-271-3000
Mailing Address - Fax:313-271-3003
Practice Address - Street 1:16407 SOUTHFIELD RD
Practice Address - Street 2:
Practice Address - City:ALLEN PARK
Practice Address - State:MI
Practice Address - Zip Code:48101
Practice Address - Country:US
Practice Address - Phone:313-271-3000
Practice Address - Fax:313-271-3003
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2019-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301076287207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
0Q26434013Medicare PIN