Healthcare Provider Details

I. General information

NPI: 1003310707
Provider Name (Legal Business Name): MADHULIKA MAMIDI MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2018
Last Update Date: 10/31/2024
Certification Date: 10/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6350 GLENWAY AVE # 4
CINCINNATI OH
45211-6378
US

IV. Provider business mailing address

6350 GLENWAY AVE # 4
CINCINNATI OH
45211-6378
US

V. Phone/Fax

Practice location:
  • Phone: 513-481-0900
  • Fax: 513-481-0904
Mailing address:
  • Phone: 513-481-0900
  • Fax: 513-481-0904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number35.148440
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: