Provider Demographics
NPI:1639433188
Name:MADALA, HARISH (MD)
Entity Type:Individual
Prefix:
First Name:HARISH
Middle Name:
Last Name:MADALA
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 1:460 NORTHSIDE CHEROKEE BLVD STE 450
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:GA
Mailing Address - Zip Code:30115-8020
Mailing Address - Country:US
Mailing Address - Phone:770-721-3800
Mailing Address - Fax:276-679-6912
Practice Address - Street 1:460 NORTHSIDE CHEROKEE BLVD STE 450
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:GA
Practice Address - Zip Code:30115-8020
Practice Address - Country:US
Practice Address - Phone:770-721-3800
Practice Address - Fax:770-720-1890
Is Sole Proprietor?:No
Enumeration Date:2012-06-29
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301099976207R00000X
VA0101264035207RH0003X
GA91670207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA91670OtherGEORGIA MEDICAL LICENSE