Provider Demographics
NPI:1932426293
Name:VADLAMUDI, PHANI DEEPTHI (MD)
Entity Type:Individual
Prefix:
First Name:PHANI DEEPTHI
Middle Name:
Last Name:VADLAMUDI
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 1:815 N CLARE AVE
Mailing Address - Street 2:
Mailing Address - City:HARRISON
Mailing Address - State:MI
Mailing Address - Zip Code:48625-9194
Mailing Address - Country:US
Mailing Address - Phone:989-539-5261
Mailing Address - Fax:
Practice Address - Street 1:815 N CLARE AVE
Practice Address - Street 2:
Practice Address - City:HARRISON
Practice Address - State:MI
Practice Address - Zip Code:48625-9194
Practice Address - Country:US
Practice Address - Phone:989-539-5261
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-04-27
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301103017207Q00000X
OK27761207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine