Provider Demographics
NPI:1255372058
Name:KODALI, SRINIVASA RAO
Entity type:Individual
Prefix:DR
First Name:SRINIVASA
Middle Name:RAO
Last Name:KODALI
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17940 FARMINGTON ROAD
Mailing Address - Street 2:SUITE 230
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-3194
Mailing Address - Country:US
Mailing Address - Phone:734-422-4748
Mailing Address - Fax:734-422-5076
Practice Address - Street 1:17940 FARMINGTON ROAD
Practice Address - Street 2:SUITE 230
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-3194
Practice Address - Country:US
Practice Address - Phone:734-422-4748
Practice Address - Fax:734-422-5076
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-10
Last Update Date:2015-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010498902084P0800X, 2084P0802X, 2084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0802XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyAddiction Psychiatry
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIOP57430Medicare PIN
MIA79143Medicare UPIN