Provider Demographics
NPI:1972164986
Name:MOKU, SUSHRUTH REDDY (DO)
Entity Type:Individual
Prefix:DR
First Name:SUSHRUTH
Middle Name:REDDY
Last Name:MOKU
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1859 PRESERVE BLVD
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48188-2221
Mailing Address - Country:US
Mailing Address - Phone:607-731-5390
Mailing Address - Fax:
Practice Address - Street 1:10000 TELEGRAPH RD
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180-3330
Practice Address - Country:US
Practice Address - Phone:313-295-5000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-21
Last Update Date:2019-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5151013968208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty