Provider Demographics
NPI:1639301328
Name:JAKKULA, MADHAVI (MD)
Entity Type:Individual
Prefix:MRS
First Name:MADHAVI
Middle Name:
Last Name:JAKKULA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MRS
Other - First Name:MADHAVI
Other - Middle Name:
Other - Last Name:JAKKULA
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:9400 TUKEY LAKE RD
Mailing Address - Street 2:MP 452
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32819
Mailing Address - Country:US
Mailing Address - Phone:321-843-5500
Mailing Address - Fax:321-843-5550
Practice Address - Street 1:9400 TUKEY LAKE RD
Practice Address - Street 2:MP 452
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32819
Practice Address - Country:US
Practice Address - Phone:321-843-5500
Practice Address - Fax:321-843-5550
Is Sole Proprietor?:Yes
Enumeration Date:2009-08-14
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME113523207R00000X, 208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL005984700Medicaid
FLME113523OtherMEDICAL LICENSE
FLGM981YMedicare PIN