Healthcare Provider Details

I. General information

NPI: 1467040501
Provider Name (Legal Business Name): SUPRADEEP SHREE VENKATA MADDURI
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2021
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date: 02/02/2022
Reactivation Date: 03/31/2026

III. Provider practice location address

4500 SAN PABLO RD S
JACKSONVILLE FL
32224-1865
US

IV. Provider business mailing address

PO BOX 860912
MINNEAPOLIS MN
55486-0912
US

V. Phone/Fax

Practice location:
  • Phone: 904-953-2000
  • Fax:
Mailing address:
  • Phone: 904-953-2000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License NumberTRN46196
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: