Provider Demographics
NPI:1558506717
Name:MADDALI, VANDANA (MD)
Entity Type:Individual
Prefix:DR
First Name:VANDANA
Middle Name:
Last Name:MADDALI
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 1:11801 SOUTH FWY
Mailing Address - Street 2:
Mailing Address - City:BURLESON
Mailing Address - State:TX
Mailing Address - Zip Code:76028-7021
Mailing Address - Country:US
Mailing Address - Phone:817-568-5955
Mailing Address - Fax:817-568-5956
Practice Address - Street 1:11801 SOUTH FWY
Practice Address - Street 2:
Practice Address - City:BURLESON
Practice Address - State:TX
Practice Address - Zip Code:76028-7021
Practice Address - Country:US
Practice Address - Phone:817-568-5955
Practice Address - Fax:817-568-5956
Is Sole Proprietor?:Yes
Enumeration Date:2008-12-02
Last Update Date:2015-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN4565207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX208067301Medicaid
TX208067301Medicaid