Provider Demographics
NPI:1265490072
Name:PENTYALA, MADHAVI (MD)
Entity Type:Individual
Prefix:
First Name:MADHAVI
Middle Name:
Last Name:PENTYALA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MADHAVI
Other - Middle Name:
Other - Last Name:KAKUMANU
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1 SCHANCK DR
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08820-2417
Mailing Address - Country:US
Mailing Address - Phone:973-992-0658
Mailing Address - Fax:973-992-6655
Practice Address - Street 1:22 OLD SHORT HILLS RD
Practice Address - Street 2:SUITE 213
Practice Address - City:LIVINGSTON
Practice Address - State:NJ
Practice Address - Zip Code:07039-5604
Practice Address - Country:US
Practice Address - Phone:973-992-0658
Practice Address - Fax:973-992-6655
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-02
Last Update Date:2014-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07939700207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0079855Medicaid
NJ094325SW7Medicare ID - Type Unspecified
NJ0079855Medicaid