Healthcare Provider Details

I. General information

NPI: 1952525115
Provider Name (Legal Business Name): PRASUNA MADHAVARAM MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 09/12/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

621 HUNTINGTON RIDGE RD NE
CEDAR RAPIDS IA
52402-7308
US

IV. Provider business mailing address

621 HUNTINGTON RIDGE RD NE
CEDAR RAPIDS IA
52402-7308
US

V. Phone/Fax

Practice location:
  • Phone: 501-258-4426
  • Fax:
Mailing address:
  • Phone: 501-258-4426
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number40130
License Number StateIA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: