Provider Demographics
NPI:1316038136
Name:MADDUR, JAYA H (MD)
Entity Type:Individual
Prefix:
First Name:JAYA
Middle Name:H
Last Name:MADDUR
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 1:111 EL CAMINO REAL
Mailing Address - Street 2:
Mailing Address - City:SIERRA VISTA
Mailing Address - State:AZ
Mailing Address - Zip Code:85635-2807
Mailing Address - Country:US
Mailing Address - Phone:520-459-3850
Mailing Address - Fax:520-459-3857
Practice Address - Street 1:111 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:SIERRA VISTA
Practice Address - State:AZ
Practice Address - Zip Code:85635-2807
Practice Address - Country:US
Practice Address - Phone:520-459-3850
Practice Address - Fax:520-459-3857
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ14396207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
C99915Medicare UPIN