Healthcare Provider Details

I. General information

NPI: 1356903306
Provider Name (Legal Business Name): MADHAVI MADUPURI MBBS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2019
Last Update Date: 04/21/2026
Certification Date: 04/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 TEBEAU ST
WAYCROSS GA
31501-6357
US

IV. Provider business mailing address

1900 TEBEAU ST
WAYCROSS GA
31501-6357
US

V. Phone/Fax

Practice location:
  • Phone: 912-287-4168
  • Fax:
Mailing address:
  • Phone: 912-287-4168
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number15838
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: