Provider Demographics
NPI:1083808067
Name:MADGULA, SRIDHAR REDDY (MD)
Entity Type:Individual
Prefix:
First Name:SRIDHAR REDDY
Middle Name:
Last Name:MADGULA
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 1:1110 W MAIN ST
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72076-4304
Mailing Address - Country:US
Mailing Address - Phone:501-982-2108
Mailing Address - Fax:501-982-4951
Practice Address - Street 1:1110 W MAIN ST
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:AR
Practice Address - Zip Code:72076-4304
Practice Address - Country:US
Practice Address - Phone:501-982-2108
Practice Address - Fax:501-982-4951
Is Sole Proprietor?:Yes
Enumeration Date:2007-08-31
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE-6524207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine