Provider Demographics
NPI:1790764553
Name:BADDAM, KAVITHA (MD)
Entity Type:Individual
Prefix:
First Name:KAVITHA
Middle Name:
Last Name:BADDAM
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 1:3495 S CENTER RD
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48519-1455
Mailing Address - Country:US
Mailing Address - Phone:810-424-2011
Mailing Address - Fax:810-249-4037
Practice Address - Street 1:1515 W ATHERTON RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-5300
Practice Address - Country:US
Practice Address - Phone:810-762-1020
Practice Address - Fax:810-762-1042
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2014-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301073879207Q00000X, 207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4428736Medicaid
MI4429751Medicaid
KB073879OtherBLUE CROSS BLUE SHIELD
MI4428727Medicaid
MI4428736Medicaid
MI4429751Medicaid