Provider Demographics
NPI:1437247566
Name:KANDULA, MADHAVI (MD)
Entity Type:Individual
Prefix:
First Name:MADHAVI
Middle Name:
Last Name:KANDULA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:845 NORTH NEW BALLAS COURT
Mailing Address - Street 2:SUITE 310
Mailing Address - City:ST LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-7148
Mailing Address - Country:US
Mailing Address - Phone:314-692-0221
Mailing Address - Fax:314-692-0686
Practice Address - Street 1:845 NORTH NEW BALLAS COURT
Practice Address - Street 2:SUITE 310
Practice Address - City:ST LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-7148
Practice Address - Country:US
Practice Address - Phone:314-692-0221
Practice Address - Fax:314-692-0686
Is Sole Proprietor?:No
Enumeration Date:2006-10-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8J49207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
177308OtherBCBSMO
199611384014OtherHUMANA
199611384014OtherHUMANA