Provider Demographics
NPI:1164505624
Name:MADHUSOODANAN, KOZHUVATTASSERI PADMANABHA (MD)
Entity Type:Individual
Prefix:DR
First Name:KOZHUVATTASSERI
Middle Name:PADMANABHA
Last Name:MADHUSOODANAN
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 1:420 DELAWARE ST SE MMC 508
Mailing Address - Street 2:UNIVERSITY OF MINNESOTA PHYSICIANS
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55455
Mailing Address - Country:US
Mailing Address - Phone:612-625-3600
Mailing Address - Fax:
Practice Address - Street 1:516 DELAWARE STREET SE CLINIC 3B
Practice Address - Street 2:UNIVERSITY OF MINNESOTA PHYSICIANS
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55455
Practice Address - Country:US
Practice Address - Phone:612-625-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-20
Last Update Date:2013-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN42532207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
1053385OtherARAZ
25-00413OtherMEDICA CHOICE
IA0534461Medicaid
M011OtherTRIWEST/TRICARE
HP31284OtherHEALTHPARTNERS
MN128412600Medicaid
WI34017700Medicaid
SD7777470Medicaid
ND10387Medicaid
127916OtherUCARE
25-00021OtherMEDICA PRIMARY
MN78R23MAOtherBLUE CROSS BLUE SHIELD
1024914OtherPREFERREDONE
110007374Medicare ID - Type UnspecifiedMEDICARE
MN128412600Medicaid