Healthcare Provider Details

I. General information

NPI: 1184745788
Provider Name (Legal Business Name): PARWATI MADDALI MD PROFESSIONAL ASSOCIATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 10/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

845 EXECUTIVE LN 100
ROCKLEDGE FL
32955-3528
US

IV. Provider business mailing address

PO BOX 561527
ROCKLEDGE FL
32956-1527
US

V. Phone/Fax

Practice location:
  • Phone: 321-631-4222
  • Fax: 321-631-4302
Mailing address:
  • Phone: 321-631-4222
  • Fax: 321-631-4302

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberME0066568
License Number StateFL

VIII. Authorized Official

Name: PARWATI C MADDALI
Title or Position: PRESIDENT
Credential: MD
Phone: 321-631-4222