Provider Demographics
NPI:1982632691
Name:DANDAMUDI, VISALA (MD)
Entity Type:Individual
Prefix:DR
First Name:VISALA
Middle Name:
Last Name:DANDAMUDI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25869 KELLY RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-4997
Mailing Address - Country:US
Mailing Address - Phone:586-773-6020
Mailing Address - Fax:586-773-6093
Practice Address - Street 1:25869 KELLY RD
Practice Address - Street 2:SUITE A
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-4997
Practice Address - Country:US
Practice Address - Phone:586-773-6020
Practice Address - Fax:586-773-6093
Is Sole Proprietor?:No
Enumeration Date:2006-06-29
Last Update Date:2008-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010809372084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4658039Medicaid
MI4658039Medicaid
MII03049Medicare UPIN