Provider Demographics
NPI:1588840482
Name:MADDIKUNTA, RAJESH VENKAT (MD)
Entity Type:Individual
Prefix:DR
First Name:RAJESH
Middle Name:VENKAT
Last Name:MADDIKUNTA
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 1:719 W HAMILTON AVE STE B
Mailing Address - Street 2:
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-6970
Mailing Address - Country:US
Mailing Address - Phone:715-552-9784
Mailing Address - Fax:715-835-6370
Practice Address - Street 1:3802 OAKWOOD MALL DR
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-3016
Practice Address - Country:US
Practice Address - Phone:715-839-9280
Practice Address - Fax:715-831-0052
Is Sole Proprietor?:No
Enumeration Date:2008-01-10
Last Update Date:2022-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI43822-020207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
001520265OtherMEDICARE PROVIDER TRANSACTION ACCESS NUMBER( INDIVIDUAL PTAN)
WI029200103OtherMEDICARE PROVIDER
WI34286000Medicaid
001520265OtherMEDICARE PROVIDER TRANSACTION ACCESS NUMBER( INDIVIDUAL PTAN)
WI34286000Medicaid