Provider Demographics
NPI:1841270634
Name:KATRAGADDA, VATSALA (MD)
Entity type:Individual
Prefix:
First Name:VATSALA
Middle Name:
Last Name:KATRAGADDA
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 1:861 MONROE STREET
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-2308
Mailing Address - Country:US
Mailing Address - Phone:313-274-0774
Mailing Address - Fax:313-277-1140
Practice Address - Street 1:861 MONROE STREET
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124
Practice Address - Country:US
Practice Address - Phone:313-274-1800
Practice Address - Fax:313-274-8717
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2018-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301066984207R00000X, 174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI104623258Medicaid
MI104623258Medicaid
MIN97990002Medicare PIN