Healthcare Provider Details

I. General information

NPI: 1609954429
Provider Name (Legal Business Name): EVELYN B. MADDELA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4770 W HERNDON AVE 108
FRESNO CA
93722-8401
US

IV. Provider business mailing address

4770 W HERNDON AVE 108
FRESNO CA
93722-8401
US

V. Phone/Fax

Practice location:
  • Phone: 559-256-7990
  • Fax: 559-256-7991
Mailing address:
  • Phone: 559-256-7990
  • Fax: 559-256-7991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberC42730
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: