Healthcare Provider Details

I. General information

NPI: 1609177344
Provider Name (Legal Business Name): MADHU MUKKAMALA BS., CNIM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/11/2010
Last Update Date: 11/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

777 E GIRARD AVE 250
ENGLEWOOD CO
80113-2767
US

IV. Provider business mailing address

777 E GIRARD AVE 250
ENGLEWOOD CO
80113-2767
US

V. Phone/Fax

Practice location:
  • Phone: 720-214-2549
  • Fax:
Mailing address:
  • Phone: 720-214-2549
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZE0600X
TaxonomyElectroneurodiagnostic Specialist/Technologist
License Number1415
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: