Provider Demographics
NPI:1679101059
Name:GADDAM, SWETHA
Entity type:Individual
Prefix:
First Name:SWETHA
Middle Name:
Last Name:GADDAM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2799 W GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48202-2689
Mailing Address - Country:US
Mailing Address - Phone:313-916-7389
Mailing Address - Fax:
Practice Address - Street 1:COREWELL HEALTH WILLIAM BEAUMONT UNIVERSITY HOSPITAL
Practice Address - Street 2:3601 W 13 MILE RD,
Practice Address - City:ROYAL OAK
Practice Address - State:MI
Practice Address - Zip Code:48073
Practice Address - Country:US
Practice Address - Phone:248-898-5000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-31
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301510538207ZC0500X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207ZC0500XAllopathic & Osteopathic PhysiciansPathologyCytopathology