Provider Demographics
NPI:1174727903
Name:KUKKALLI, RAVI BHUSHAN (PT)
Entity type:Individual
Prefix:
First Name:RAVI
Middle Name:BHUSHAN
Last Name:KUKKALLI
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4020 VENOY RD STE 700
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:MI
Mailing Address - Zip Code:48184-1891
Mailing Address - Country:US
Mailing Address - Phone:734-727-1309
Mailing Address - Fax:734-727-1319
Practice Address - Street 1:4020 VENOY RD STE 700
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:MI
Practice Address - Zip Code:48184-1891
Practice Address - Country:US
Practice Address - Phone:734-727-1309
Practice Address - Fax:734-727-1319
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-14
Last Update Date:2024-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225100000X
MI5501010604225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI65-0-F3-1405-0OtherBCBSM
MIN38180003Medicare ID - Type Unspecified