Provider Demographics
NPI:1609177344
Name:MUKKAMALA, MADHU (BS, CNIM)
Entity Type:Individual
Prefix:MR
First Name:MADHU
Middle Name:
Last Name:MUKKAMALA
Suffix:
Gender:M
Credentials:BS, CNIM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:777 E GIRARD AVE
Mailing Address - Street 2:250
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80113-2767
Mailing Address - Country:US
Mailing Address - Phone:720-214-2549
Mailing Address - Fax:
Practice Address - Street 1:777 E GIRARD AVE
Practice Address - Street 2:250
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80113-2767
Practice Address - Country:US
Practice Address - Phone:720-214-2549
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-11
Last Update Date:2010-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1415246ZE0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic