Provider Demographics
NPI:1417052317
Name:WADHERA, MADHUKAR (MD)
Entity Type:Individual
Prefix:DR
First Name:MADHUKAR
Middle Name:
Last Name:WADHERA
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 1:24305 NEWHALL AVE
Mailing Address - Street 2:
Mailing Address - City:ROSEDALE
Mailing Address - State:NY
Mailing Address - Zip Code:11422-2437
Mailing Address - Country:US
Mailing Address - Phone:718-528-4125
Mailing Address - Fax:718-528-9328
Practice Address - Street 1:24305 NEWHALL AVE
Practice Address - Street 2:
Practice Address - City:ROSEDALE
Practice Address - State:NY
Practice Address - Zip Code:11422-2437
Practice Address - Country:US
Practice Address - Phone:718-528-4125
Practice Address - Fax:718-528-9328
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-14
Last Update Date:2010-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY134224207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00319631Medicaid
NY97539Medicare ID - Type Unspecified
B88876Medicare UPIN