Provider Demographics
NPI:1245260561
Name:DUDDELLA, PADMAJA (MD)
Entity type:Individual
Prefix:
First Name:PADMAJA
Middle Name:
Last Name:DUDDELLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7574 HERRICK PARK DR
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:OH
Mailing Address - Zip Code:44236-2375
Mailing Address - Country:US
Mailing Address - Phone:330-294-0294
Mailing Address - Fax:
Practice Address - Street 1:822 KUMHO DR
Practice Address - Street 2:SUITE 202
Practice Address - City:FAIRLAWN
Practice Address - State:OH
Practice Address - Zip Code:44333-9297
Practice Address - Country:US
Practice Address - Phone:330-576-0500
Practice Address - Fax:330-576-0467
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-03
Last Update Date:2009-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35077580207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2216864Medicaid
OHH24788Medicare UPIN
OH2216864Medicaid