Provider Demographics
NPI:1790843092
Name:VADLAMUDI, RAVI ALEXANDER (MD)
Entity Type:Individual
Prefix:
First Name:RAVI
Middle Name:ALEXANDER
Last Name:VADLAMUDI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1133 POMONA RD
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48103-3044
Mailing Address - Country:US
Mailing Address - Phone:734-709-2891
Mailing Address - Fax:
Practice Address - Street 1:3174 PACKARD ST
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48108-1947
Practice Address - Country:US
Practice Address - Phone:734-971-1073
Practice Address - Fax:734-971-8545
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA14008R207Q00000X
MI770482207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009913254Medicaid
LA1117749Medicaid
MI770482OtherMEDICAL LISCENCE NUMBER
LA14008ROtherMEDICAL LISCENCE NUMBER
LA14008ROtherMEDICAL LISCENCE NUMBER
LA1117749Medicaid
LA4E089Medicare PIN
AL009913254Medicaid