Healthcare Provider Details

I. General information

NPI: 1154771574
Provider Name (Legal Business Name): MADHAVI KALAVAKURI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2016
Last Update Date: 11/27/2023
Certification Date: 10/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 BAKER CIR
ADAMSTOWN MD
21710-9653
US

IV. Provider business mailing address

23007 BROADRUN MEADOW CIR
ASHBURN VA
20148-6899
US

V. Phone/Fax

Practice location:
  • Phone: 571-439-6662
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number25074
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2305210016
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: