Provider Demographics
NPI:1174710503
Name:MADALA, PADMAJA (MD)
Entity type:Individual
Prefix:
First Name:PADMAJA
Middle Name:
Last Name:MADALA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:PADMAJA
Other - Middle Name:
Other - Last Name:KAKANI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:920 LARK DR
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12207-1300
Mailing Address - Country:US
Mailing Address - Phone:518-591-4458
Mailing Address - Fax:518-242-4784
Practice Address - Street 1:920 LARK DR
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12207-1300
Practice Address - Country:US
Practice Address - Phone:518-561-4458
Practice Address - Fax:518-242-4784
Is Sole Proprietor?:No
Enumeration Date:2007-10-01
Last Update Date:2020-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY246088207Q00000X, 207QA0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400018310Medicare PIN