Provider Demographics
NPI:1043903941
Name:MUDDALOOR, PRATYUSHA (MD)
Entity Type:Individual
Prefix:
First Name:PRATYUSHA
Middle Name:
Last Name:MUDDALOOR
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 1:501 BATH RD
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:PA
Mailing Address - Zip Code:19007-3190
Mailing Address - Country:US
Mailing Address - Phone:551-327-2002
Mailing Address - Fax:
Practice Address - Street 1:501 BATH RD
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:PA
Practice Address - Zip Code:19007-3190
Practice Address - Country:US
Practice Address - Phone:215-785-9977
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-29
Last Update Date:2023-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT228586390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program