Healthcare Provider Details

I. General information

NPI: 1043903941
Provider Name (Legal Business Name): PRATYUSHA MUDDALOOR MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2023
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

750 E. ADAMS ST
SYRACUSE NY
13210
US

IV. Provider business mailing address

750 E. ADAMS ST.
SYRACUSE NY
13210
US

V. Phone/Fax

Practice location:
  • Phone: 315-464-5774
  • Fax: 315-464-5378
Mailing address:
  • Phone: 315-464-5774
  • Fax: 315-464-5378

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License NumberMT228586
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: