Provider Demographics
NPI:1871795815
Name:RAINA-HUKKU, SUPRIYA (MD)
Entity type:Individual
Prefix:DR
First Name:SUPRIYA
Middle Name:
Last Name:RAINA-HUKKU
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:SUPRIYA
Other - Middle Name:
Other - Last Name:HUKKU
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:46239 BROOKSIDE NORTH DR
Mailing Address - Street 2:
Mailing Address - City:MACOMB
Mailing Address - State:MI
Mailing Address - Zip Code:48044-5451
Mailing Address - Country:US
Mailing Address - Phone:847-932-9169
Mailing Address - Fax:
Practice Address - Street 1:2799 W GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48202-2608
Practice Address - Country:US
Practice Address - Phone:313-916-2964
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-01
Last Update Date:2020-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD185514207ZP0102X
IL036128898207ZP0102X
MI4301088570207ZP0102X
WAMD60801236207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Single Specialty