Provider Demographics
NPI:1134781040
Name:KONDURI, ANUSHA
Entity type:Individual
Prefix:
First Name:ANUSHA
Middle Name:
Last Name:KONDURI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:40 DAVENPORT ST APT 309
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2450
Mailing Address - Country:US
Mailing Address - Phone:315-928-9107
Mailing Address - Fax:
Practice Address - Street 1:3901, BEAUBIEN BLVD
Practice Address - Street 2:CHILDRENS HOSPITAL OF MICHIGAN
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201
Practice Address - Country:US
Practice Address - Phone:315-928-9107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-01
Last Update Date:2019-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4351045508390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program