Provider Demographics
NPI:1225583180
Name:PREMKUMAR, MRUDULA (MD)
Entity Type:Individual
Prefix:DR
First Name:MRUDULA
Middle Name:
Last Name:PREMKUMAR
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MRUDULA
Other - Middle Name:
Other - Last Name:MADDALI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:61 DAVIS AVE APT Q
Mailing Address - Street 2:
Mailing Address - City:WHITE PLAINS
Mailing Address - State:NY
Mailing Address - Zip Code:10605-1009
Mailing Address - Country:US
Mailing Address - Phone:973-615-6662
Mailing Address - Fax:
Practice Address - Street 1:160 N MIDLAND AVE
Practice Address - Street 2:
Practice Address - City:NYACK
Practice Address - State:NY
Practice Address - Zip Code:10960-1912
Practice Address - Country:US
Practice Address - Phone:973-615-6662
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-08-22
Last Update Date:2020-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY299538208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics