Provider Demographics
NPI:1003804097
Name:PAUL, MADHULATHA (MD)
Entity Type:Individual
Prefix:
First Name:MADHULATHA
Middle Name:
Last Name:PAUL
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:PO BOX 827783
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19182-7783
Mailing Address - Country:US
Mailing Address - Phone:215-707-8496
Mailing Address - Fax:215-707-4086
Practice Address - Street 1:100 E LEHIGH AVE
Practice Address - Street 2:MAB BLDG STE 105
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19125-1000
Practice Address - Country:US
Practice Address - Phone:215-707-8496
Practice Address - Fax:215-707-4086
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2010-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD039044L2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA11526061224269Medicaid
PA11526061224269Medicaid
474947Medicare ID - Type Unspecified