Provider Demographics
NPI:1013126358
Name:MALLU, SRILATHA (MD)
Entity Type:Individual
Prefix:DR
First Name:SRILATHA
Middle Name:
Last Name:MALLU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:SRILATHA
Other - Middle Name:
Other - Last Name:VODUR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:28849 HEARTHSTONE DR
Mailing Address - Street 2:
Mailing Address - City:NOVI
Mailing Address - State:MI
Mailing Address - Zip Code:48377-2722
Mailing Address - Country:US
Mailing Address - Phone:248-438-1038
Mailing Address - Fax:
Practice Address - Street 1:2799 W GRAND BLVD
Practice Address - Street 2:HENRY FORD HOSPITAL
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2608
Practice Address - Country:US
Practice Address - Phone:313-916-4872
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-22
Last Update Date:2011-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-096328207L00000X
MI4301079527207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology