Provider Demographics
NPI:1265458624
Name:GUMMADI, HIMAJA (MD)
Entity type:Individual
Prefix:
First Name:HIMAJA
Middle Name:
Last Name:GUMMADI
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 1:172 QUEEN ANNE DR
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-4682
Mailing Address - Country:US
Mailing Address - Phone:734-397-1805
Mailing Address - Fax:
Practice Address - Street 1:30901 PALMER RD
Practice Address - Street 2:
Practice Address - City:WESTLAND
Practice Address - State:MI
Practice Address - Zip Code:48186-9529
Practice Address - Country:US
Practice Address - Phone:734-367-8403
Practice Address - Fax:734-722-9524
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI43010701282084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI260Q26259OtherBCBSM GR#
MI4867342Medicaid
MIHG070108OtherLICENSE
MI1508883299OtherWRPH
MI2600052028OtherRAILROAD
MIH27135Medicare UPIN
MI4867342Medicaid