Provider Demographics
NPI:1548835184
Name:LIYANAARACHCHI, BHAVANA PABBATI (DO)
Entity type:Individual
Prefix:
First Name:BHAVANA
Middle Name:PABBATI
Last Name:LIYANAARACHCHI
Suffix:
Gender:
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44190 DEEP HOLLOW CIR
Mailing Address - Street 2:
Mailing Address - City:NORTHVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48168-8414
Mailing Address - Country:US
Mailing Address - Phone:303-330-3630
Mailing Address - Fax:
Practice Address - Street 1:11885 E 12 MILE RD STE 300A
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-3467
Practice Address - Country:US
Practice Address - Phone:586-582-6630
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-25
Last Update Date:2025-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101028151208M00000X, 207R00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program