Provider Demographics
NPI:1447238035
Name:MADDURI, SIVAPRASAD D (MD)
Entity Type:Individual
Prefix:
First Name:SIVAPRASAD
Middle Name:D
Last Name:MADDURI
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 1:2210 BARRON RD
Mailing Address - Street 2:SUITE 216
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-1908
Mailing Address - Country:US
Mailing Address - Phone:573-686-4133
Mailing Address - Fax:573-686-1298
Practice Address - Street 1:2210 BARRON RD
Practice Address - Street 2:SUITE 216
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-1908
Practice Address - Country:US
Practice Address - Phone:573-686-4133
Practice Address - Fax:573-686-1298
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-04
Last Update Date:2013-10-01
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MOR7648208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR108024001OtherARKANSAS MEDICAID
MO200297117Medicaid
MO000096269Medicare PIN
MOP00382850Medicare PIN
MO200297117Medicaid