Provider Demographics
NPI:1043272719
Name:MADDELA, ELIZABETH (MD)
Entity Type:Individual
Prefix:DR
First Name:ELIZABETH
Middle Name:
Last Name:MADDELA
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 1:476 KLONDIKE AVE
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-6216
Mailing Address - Country:US
Mailing Address - Phone:718-761-1156
Mailing Address - Fax:718-761-1047
Practice Address - Street 1:476 KLONDIKE AVE
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10314-6216
Practice Address - Country:US
Practice Address - Phone:718-761-1156
Practice Address - Fax:718-761-1047
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY155116207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA59985Medicare UPIN
NY02E461Medicare ID - Type Unspecified