Provider Demographics
NPI:1952419400
Name:PULLUKAT, ANNAMMA S (MD)
Entity Type:Individual
Prefix:DR
First Name:ANNAMMA
Middle Name:S
Last Name:PULLUKAT
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 1:44200 WOODWARD AVE
Mailing Address - Street 2:103
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48341-5045
Mailing Address - Country:US
Mailing Address - Phone:248-253-9600
Mailing Address - Fax:248-253-0980
Practice Address - Street 1:44200 WOODWARD AVE
Practice Address - Street 2:103
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-5045
Practice Address - Country:US
Practice Address - Phone:248-253-9600
Practice Address - Fax:248-253-0980
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-25
Last Update Date:2017-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301043370208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI212145310Medicaid
MI212145310Medicaid