Healthcare Provider Details

I. General information

NPI: 1144266065
Provider Name (Legal Business Name): MADHAVI MADUGULA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2006
Last Update Date: 12/17/2021
Certification Date: 11/03/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 FORT JESSE RD SUITE 110
NORMAL IL
61761-6286
US

IV. Provider business mailing address

4501 SAND CREEK RD
ANTIOCH CA
94531-8687
US

V. Phone/Fax

Practice location:
  • Phone: 309-661-6290
  • Fax: 309-451-1354
Mailing address:
  • Phone: 810-964-3246
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4301085702
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: