Provider Demographics
NPI:1467991034
Name:MADURI, PRATHUSHA
Entity Type:Individual
Prefix:
First Name:PRATHUSHA
Middle Name:
Last Name:MADURI
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2637 N 400 E # 164
Mailing Address - Street 2:
Mailing Address - City:NORTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84414-2240
Mailing Address - Country:US
Mailing Address - Phone:214-970-6817
Mailing Address - Fax:844-803-4513
Practice Address - Street 1:2304 HIGHWAY 121
Practice Address - Street 2:
Practice Address - City:BEDFORD
Practice Address - State:TX
Practice Address - Zip Code:76021-5985
Practice Address - Country:US
Practice Address - Phone:214-970-6817
Practice Address - Fax:844-803-4513
Is Sole Proprietor?:No
Enumeration Date:2017-02-16
Last Update Date:2023-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS021883208100000X
TXU2255208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation