Provider Demographics
NPI:1184650772
Name:MADALA, DURGA VENKATALAKSH (MD)
Entity Type:Individual
Prefix:
First Name:DURGA
Middle Name:VENKATALAKSH
Last Name:MADALA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2516 SAMARITAN DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95124-4108
Mailing Address - Country:US
Mailing Address - Phone:408-356-4242
Mailing Address - Fax:408-356-4455
Practice Address - Street 1:2516 SAMARITAN DR
Practice Address - Street 2:SUITE A
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95124-4108
Practice Address - Country:US
Practice Address - Phone:408-356-4242
Practice Address - Fax:408-356-4455
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-24
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA56316207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAI01146Medicare UPIN