Provider Demographics
NPI:1740486349
Name:PABBATHI, PRATHIMA (MD)
Entity type:Individual
Prefix:DR
First Name:PRATHIMA
Middle Name:
Last Name:PABBATHI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:PRATHIMA
Other - Middle Name:
Other - Last Name:NALLABANTU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1540 LAKE LANSING RD
Mailing Address - Street 2:SUITE 201
Mailing Address - City:LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48912-3756
Mailing Address - Country:US
Mailing Address - Phone:517-913-3900
Mailing Address - Fax:517-913-3901
Practice Address - Street 1:1540 LAKE LANSING RD
Practice Address - Street 2:SUITE 201
Practice Address - City:LANSING
Practice Address - State:MI
Practice Address - Zip Code:48912-3756
Practice Address - Country:US
Practice Address - Phone:517-913-3900
Practice Address - Fax:517-913-3901
Is Sole Proprietor?:No
Enumeration Date:2007-06-21
Last Update Date:2011-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301089892207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI200000025762OtherPHP- COMMERCIAL
MI0803304652OtherBLUE CROSS BLUE SHIELD OF MICHIGAN/BLUE CARE NETWORK
MIP00893152OtherRAILROAD MEDICARE
MI1065666OtherMCLAREN HEALTH PLAN-MEDICAID
MI1065666OtherMCLAREN HEALTH PLAN-COMMERCIAL
MI9402523OtherAETNA
MI0M21440078OtherMEDICARE PLUS BLUE
MI1065666OtherMCLAREN HEALTH ADVANTAGE
MI200000025762OtherPHP- FAMILYCARE
MI1065666OtherMCLAREN HEALTH PLAN-MEDICAID