Provider Demographics
NPI:1144228891
Name:JONNALAGADDA, PADMAVATHI (MD)
Entity Type:Individual
Prefix:
First Name:PADMAVATHI
Middle Name:
Last Name:JONNALAGADDA
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 1:3438 JOHN F KENNEDY BLVD
Mailing Address - Street 2:
Mailing Address - City:JERSEY CITY
Mailing Address - State:NJ
Mailing Address - Zip Code:07307-4166
Mailing Address - Country:US
Mailing Address - Phone:201-420-0366
Mailing Address - Fax:201-420-6422
Practice Address - Street 1:3438 JOHN F KENNEDY BLVD
Practice Address - Street 2:
Practice Address - City:JERSEY CITY
Practice Address - State:NJ
Practice Address - Zip Code:07307-4166
Practice Address - Country:US
Practice Address - Phone:201-420-0366
Practice Address - Fax:201-420-6422
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07442900207R00000X
NY225330-1207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJDB2462OtherRAILROAD MEDICARE GROUP #
NJ9006508Medicaid
NJ0036536Medicaid
NJ043714808OtherHORIZON B/ C B/S
NY02511508Medicaid
NJP00089969OtherRAILROAD MEDICARE INDIVID
NY02511508Medicaid
NJ067842SJ1Medicare ID - Type UnspecifiedINDIVIDUAL NUMBER
NJ9006508Medicaid