Provider Demographics
NPI:1720166713
Name:NANNAPANENI, SUDHA (MD)
Entity Type:Individual
Prefix:DR
First Name:SUDHA
Middle Name:
Last Name:NANNAPANENI
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 1:18285 TEN MILE
Mailing Address - Street 2:120
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-5806
Mailing Address - Country:US
Mailing Address - Phone:586-771-4830
Mailing Address - Fax:586-771-3115
Practice Address - Street 1:18285 TEN MILE
Practice Address - Street 2:120
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-5806
Practice Address - Country:US
Practice Address - Phone:586-771-4830
Practice Address - Fax:586-771-3115
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2011-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301070308207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1105010442OtherBCBS
MI4290526Medicaid
MI1105010442OtherBCBS
MI0N13360Medicare ID - Type Unspecified