Provider Demographics
NPI:1790764553
Name:BADDAM, KAVITHA (MD)
Entity type:Individual
Prefix:
First Name:KAVITHA
Middle Name:
Last Name:BADDAM
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 1:3495 S CENTER RD
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48519-1455
Mailing Address - Country:US
Mailing Address - Phone:810-424-2011
Mailing Address - Fax:810-249-4037
Practice Address - Street 1:1096 S BELSAY RD STE E
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48509-1948
Practice Address - Country:US
Practice Address - Phone:810-762-1020
Practice Address - Fax:810-762-1042
Is Sole Proprietor?:No
Enumeration Date:2006-01-11
Last Update Date:2025-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301073879207PE0004X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4428736Medicaid
KB073879OtherBLUE CROSS BLUE SHIELD
MI4428727Medicaid
MI4429751Medicaid
MI4428736Medicaid
MI4429751Medicaid