Provider Demographics
NPI:1235137670
Name:MADDALI, ANNAPURNA JASTI (MD)
Entity Type:Individual
Prefix:DR
First Name:ANNAPURNA
Middle Name:JASTI
Last Name:MADDALI
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 1:10663 LOVELAND MADEIRA RD
Mailing Address - Street 2:SUITE-279
Mailing Address - City:LOVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:45140-8965
Mailing Address - Country:US
Mailing Address - Phone:513-244-8866
Mailing Address - Fax:
Practice Address - Street 1:10663 LOVELAND MADEIRA RD
Practice Address - Street 2:SUITE-279
Practice Address - City:LOVELAND
Practice Address - State:OH
Practice Address - Zip Code:45140-8965
Practice Address - Country:US
Practice Address - Phone:513-244-8866
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-07-11
Last Update Date:2011-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35071617207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2019130Medicaid
OH4020258Medicare PIN
G50594Medicare UPIN