Provider Demographics
NPI:1386689644
Name:KALYAN, MADHU T (MD)
Entity Type:Individual
Prefix:DR
First Name:MADHU
Middle Name:T
Last Name:KALYAN
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 1:601 W MAPLE AVE
Mailing Address - Street 2:SUITE 704
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72764-5335
Mailing Address - Country:US
Mailing Address - Phone:479-757-3717
Mailing Address - Fax:479-856-5307
Practice Address - Street 1:601 W MAPLE AVE STE 101
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72764-5370
Practice Address - Country:US
Practice Address - Phone:479-757-4720
Practice Address - Fax:479-757-2995
Is Sole Proprietor?:No
Enumeration Date:2006-06-19
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE3298174400000X
ARE-3298207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200008290AMedicaid
ARP00196415OtherRR MCR
AR146947001Medicaid
AR5H893OtherMEDICARE PTAN