Provider Demographics
NPI:1942433289
Name:KOTTUKAPALLY, NOBIN J (MD)
Entity Type:Individual
Prefix:
First Name:NOBIN
Middle Name:J
Last Name:KOTTUKAPALLY
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 1:50375 UPTOWN AVE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-6662
Mailing Address - Country:US
Mailing Address - Phone:810-877-0848
Mailing Address - Fax:
Practice Address - Street 1:2001 S MERRIMAN RD
Practice Address - Street 2:SUITE 100
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48186-5539
Practice Address - Country:US
Practice Address - Phone:585-279-4800
Practice Address - Fax:585-244-9048
Is Sole Proprietor?:No
Enumeration Date:2009-09-03
Last Update Date:2020-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY266204207Q00000X
MI4301094236207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine