Provider Demographics
NPI:1265669089
Name:BHOOMAGOUD, MADHAVI (MD)
Entity Type:Individual
Prefix:
First Name:MADHAVI
Middle Name:
Last Name:BHOOMAGOUD
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 1:455 LEWIS AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:MERIDEN
Mailing Address - State:CT
Mailing Address - Zip Code:06451-2121
Mailing Address - Country:US
Mailing Address - Phone:203-237-2477
Mailing Address - Fax:203-238-1839
Practice Address - Street 1:455 LEWIS AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:MERIDEN
Practice Address - State:CT
Practice Address - Zip Code:06451-2121
Practice Address - Country:US
Practice Address - Phone:203-237-2477
Practice Address - Fax:203-238-1839
Is Sole Proprietor?:No
Enumeration Date:2009-06-18
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT047262207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT047262OtherLICENSE