Provider Demographics
NPI:1487762647
Name:MADDULA, MALLAREDDY (MD)
Entity type:Individual
Prefix:DR
First Name:MALLAREDDY
Middle Name:
Last Name:MADDULA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 E MARCH LN
Mailing Address - Street 2:SUITE B265
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95210-6629
Mailing Address - Country:US
Mailing Address - Phone:209-546-1868
Mailing Address - Fax:209-461-6505
Practice Address - Street 1:1801 E MARCH LN
Practice Address - Street 2:SUITE B265
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95210-6629
Practice Address - Country:US
Practice Address - Phone:209-546-1868
Practice Address - Fax:209-461-6505
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2011-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME96158207RN0300X
CAA108120207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA108120OtherSTATE LICENSE
CACB971ZOtherMEDICARE
I08855Medicare UPIN