Provider Demographics
NPI:1275521288
Name:KANDULA, MADAN N (MD)
Entity Type:Individual
Prefix:DR
First Name:MADAN
Middle Name:N
Last Name:KANDULA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10001 W INNOVATION DR STE 200
Mailing Address - Street 2:
Mailing Address - City:WAUWATOSA
Mailing Address - State:WI
Mailing Address - Zip Code:53226-4851
Mailing Address - Country:US
Mailing Address - Phone:414-771-6780
Mailing Address - Fax:414-238-2424
Practice Address - Street 1:2885 N MAYFAIR RD
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53222-4404
Practice Address - Country:US
Practice Address - Phone:414-771-6780
Practice Address - Fax:414-238-2424
Is Sole Proprietor?:No
Enumeration Date:2005-10-12
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI44930-020207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI20-1759813OtherCORPORATION TAX ID
WI34336200Medicaid
WI20-1759813OtherCORPORATION TAX ID
WIH78750Medicare UPIN