Provider Demographics
NPI:1114100591
Name:MADALA, DAS B
Entity Type:Individual
Prefix:MR
First Name:DAS
Middle Name:B
Last Name:MADALA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 PENN PLZ
Mailing Address - Street 2:PENN STATION AMTRAK LEVEL
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10121-0101
Mailing Address - Country:US
Mailing Address - Phone:212-760-8107
Mailing Address - Fax:
Practice Address - Street 1:2 PENN PLZ
Practice Address - Street 2:PENN STATION AMTRAK LEVEL
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10121-0101
Practice Address - Country:US
Practice Address - Phone:212-760-8107
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-09
Last Update Date:2007-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY032429183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01308621Medicaid