Provider Demographics
NPI:1245382704
Name:REDDY, MADHAVI THUKIVAKAM (MD)
Entity Type:Individual
Prefix:
First Name:MADHAVI
Middle Name:THUKIVAKAM
Last Name:REDDY
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 1:33 EAST CHESTNUT AVENUE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19118-2713
Mailing Address - Country:US
Mailing Address - Phone:215-248-1350
Mailing Address - Fax:
Practice Address - Street 1:33 EAST CHESTNUT AVENUE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19118-2713
Practice Address - Country:US
Practice Address - Phone:215-248-1350
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-17
Last Update Date:2012-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.201257207RC0000X
IL036-116563207R00000X
PAMD446760207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1457558Medicaid
MS03672328Medicaid
MS03672328Medicaid