Provider Demographics
NPI:1780738047
Name:THALLA, RADHIKA K (MD)
Entity type:Individual
Prefix:DR
First Name:RADHIKA
Middle Name:K
Last Name:THALLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:RADHIKA
Other - Middle Name:
Other - Last Name:KATAKAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:47652 ADRIANA CT
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-1336
Mailing Address - Country:US
Mailing Address - Phone:734-237-1923
Mailing Address - Fax:
Practice Address - Street 1:27901 WOODWARD AVE
Practice Address - Street 2:SUITE #210
Practice Address - City:BERKLEY
Practice Address - State:MI
Practice Address - Zip Code:48072-0919
Practice Address - Country:US
Practice Address - Phone:248-414-5377
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2009-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301089117207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine