Provider Demographics
NPI:1790775195
Name:LAKKARAJU, RAVI KIRAN (MD)
Entity Type:Individual
Prefix:MR
First Name:RAVI
Middle Name:KIRAN
Last Name:LAKKARAJU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:6022 E MEADOW DR
Mailing Address - Street 2:
Mailing Address - City:BAY CITY
Mailing Address - State:MI
Mailing Address - Zip Code:48706-9081
Mailing Address - Country:US
Mailing Address - Phone:989-667-6650
Mailing Address - Fax:989-667-6660
Practice Address - Street 1:3190 E MIDLAND RD
Practice Address - Street 2:
Practice Address - City:BAY CITY
Practice Address - State:MI
Practice Address - Zip Code:48706-2755
Practice Address - Country:US
Practice Address - Phone:989-667-6650
Practice Address - Fax:989-667-6660
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-26
Last Update Date:2010-01-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MIRL077577208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIRL077577OtherSTATE LICENSE
MI4442940Medicaid
MI4442940Medicaid
H37305Medicare UPIN