Provider Demographics
NPI:1417013368
Name:BADAM, MANJULATHA (MD)
Entity Type:Individual
Prefix:DR
First Name:MANJULATHA
Middle Name:
Last Name:BADAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MANJULATHA
Other - Middle Name:
Other - Last Name:NUKALA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD, CWSP, UHM
Mailing Address - Street 1:13423 BLANCO RD # 767
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78216-2187
Mailing Address - Country:US
Mailing Address - Phone:210-651-1112
Mailing Address - Fax:855-479-2049
Practice Address - Street 1:8666 HUEBNER RD STE 220
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78240-1837
Practice Address - Country:US
Practice Address - Phone:210-951-9981
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXM7480207R00000X, 2083P0011X
VA0101242906207R00000X
PAMD435857207R00000X
DC0101242906207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2083P0011XAllopathic & Osteopathic PhysiciansPreventive MedicineUndersea and Hyperbaric MedicineGroup - Single Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1417013368Medicaid
PANU2081271OtherHIGHMARK BCBS
PAP00730148OtherRAILROAD MEDICARE
TX186301104Medicaid
PA102300410 0001Medicaid
TX186301104Medicaid
PANU2081271OtherHIGHMARK BCBS
PAP00730148OtherRAILROAD MEDICARE
TX323828YMVQMedicare PIN