Basic Information
| Provider Information | |||||||||
| NPI: | 1003811662 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | YALAVARTHI | ||||||||
| FirstName: | JYOTHSNA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 36123 SCHOOLCRAFT RD | ||||||||
| Address2: | |||||||||
| City: | LIVONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481501216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344640887 | ||||||||
| FaxNumber: | 7344020254 | ||||||||
| Practice Location | |||||||||
| Address1: | 28050 GRAND RIVER AVE | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483365919 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344640887 | ||||||||
| FaxNumber: | 7344020254 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/20/2005 | ||||||||
| LastUpdateDate: | 07/29/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 35079536 | OH | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 4301097794 | MI | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 4301097794 | MI | N | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 1003811662 | 05 | MI | MEDICAID |