Provider Demographics
NPI:1376552901
Name:MADINEEDI, MANGADHARA RAO (MD, MSA, FACP)
Entity Type:Individual
Prefix:DR
First Name:MANGADHARA
Middle Name:RAO
Last Name:MADINEEDI
Suffix:
Gender:M
Credentials:MD, MSA, FACP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:940 BELMONT ST
Mailing Address - Street 2:
Mailing Address - City:BROCKTON
Mailing Address - State:MA
Mailing Address - Zip Code:02301-5596
Mailing Address - Country:US
Mailing Address - Phone:508-583-4500
Mailing Address - Fax:774-826-3157
Practice Address - Street 1:940 BELMONT ST
Practice Address - Street 2:GERIATRICS & EXTENDED CARE SERVICE LINE (181)
Practice Address - City:BROCKTON
Practice Address - State:MA
Practice Address - Zip Code:02301-5596
Practice Address - Country:US
Practice Address - Phone:774-826-1860
Practice Address - Fax:774-826-2643
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-05
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA79686207RG0300X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3136809Medicaid
MAMM0137186ASOtherSTATE CONTROLLED SUBSTANC
MAMM0137186ASOtherSTATE CONTROLLED SUBSTANC
MA3136809Medicaid
MAMM0137186ASOtherSTATE CONTROLLED SUBSTANC