Provider Demographics
NPI:1114017969
Name:MADUPU, GANGADHAR (MD)
Entity Type:Individual
Prefix:
First Name:GANGADHAR
Middle Name:
Last Name:MADUPU
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 1:1617 N JAMES ST
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:NY
Mailing Address - Zip Code:13440-2852
Mailing Address - Country:US
Mailing Address - Phone:315-533-1025
Mailing Address - Fax:315-533-1006
Practice Address - Street 1:1617 N JAMES ST
Practice Address - Street 2:
Practice Address - City:ROME
Practice Address - State:NY
Practice Address - Zip Code:13440-2852
Practice Address - Country:US
Practice Address - Phone:315-533-1025
Practice Address - Fax:315-533-1006
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2165192084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
10049766OtherCDPHP
3099103OtherGHI
NY13625OtherMVP
NY02112967Medicaid
NY02112967Medicaid
3099103OtherGHI