Provider Demographics
NPI:1093093619
Name:UNNIKRISHNAN, MADHU (MBBS)
Entity Type:Individual
Prefix:DR
First Name:MADHU
Middle Name:
Last Name:UNNIKRISHNAN
Suffix:
Gender:M
Credentials:MBBS
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 102222
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30368-2222
Mailing Address - Country:US
Mailing Address - Phone:239-432-8500
Mailing Address - Fax:
Practice Address - Street 1:61 MEMORIAL MEDICAL PKWY STE 2818
Practice Address - Street 2:
Practice Address - City:PALM COAST
Practice Address - State:FL
Practice Address - Zip Code:32164-5999
Practice Address - Country:US
Practice Address - Phone:386-586-2889
Practice Address - Fax:386-286-2890
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-31
Last Update Date:2023-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH123669207R00000X
ND14498207RH0000X, 207RX0202X
FLME159209207RH0000X, 207RX0202X
WAMD61116309207RH0003X
WI82510207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RH0000XAllopathic & Osteopathic PhysiciansInternal MedicineHematology
No207RX0202XAllopathic & Osteopathic PhysiciansInternal MedicineMedical Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL115729300Medicaid