Healthcare Provider Details

I. General information

NPI: 1659571867
Provider Name (Legal Business Name): ADITYA KUMAR RANGBULLA M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2007
Last Update Date: 05/07/2021
Certification Date: 05/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 S MADISON ST
APPLETON WI
54915-1846
US

IV. Provider business mailing address

1501 S MADISON ST
APPLETON WI
54915-1846
US

V. Phone/Fax

Practice location:
  • Phone: 920-730-4414
  • Fax:
Mailing address:
  • Phone: 920-730-4414
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number54650
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: