Provider Demographics
NPI:1942719125
Name:BONGURALA, ARCHANA REDDY (MD)
Entity Type:Individual
Prefix:
First Name:ARCHANA
Middle Name:REDDY
Last Name:BONGURALA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3535 W 13 MILE RD
Mailing Address - Street 2:
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-6770
Mailing Address - Country:US
Mailing Address - Phone:248-551-3000
Mailing Address - Fax:248-551-2032
Practice Address - Street 1:3535 WEST 13 MILE RD
Practice Address - Street 2:SOUTH CLINIC
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073
Practice Address - Country:US
Practice Address - Phone:248-551-3000
Practice Address - Fax:248-551-2032
Is Sole Proprietor?:No
Enumeration Date:2017-09-20
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301112602208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics