Provider Demographics
NPI:1740794312
Name:PRASAD MIKKILINENI MD
Entity Type:Organization
Organization Name:PRASAD MIKKILINENI MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLER
Authorized Official - Prefix:MS
Authorized Official - First Name:IRENE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:MARTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-675-4273
Mailing Address - Street 1:18576 SHADYSIDE ST
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-3246
Mailing Address - Country:US
Mailing Address - Phone:734-674-2739
Mailing Address - Fax:
Practice Address - Street 1:36975 FIVE MILE RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48154-1871
Practice Address - Country:US
Practice Address - Phone:734-464-0600
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-11-19
Last Update Date:2017-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301039936207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric MedicineGroup - Single Specialty