Provider Demographics
NPI:1669475497
Name:MADDALI, PARWATI C (MD)
Entity Type:Individual
Prefix:DR
First Name:PARWATI
Middle Name:C
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:PO BOX 561527
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32956-1527
Mailing Address - Country:US
Mailing Address - Phone:321-631-4222
Mailing Address - Fax:321-631-4302
Practice Address - Street 1:845 EXECUTIVE LN
Practice Address - Street 2:100
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-3528
Practice Address - Country:US
Practice Address - Phone:321-631-4222
Practice Address - Fax:321-631-4302
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-24
Last Update Date:2008-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME665682084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL25999OtherBCBS
FLF90019Medicare UPIN
FL25999DMedicare ID - Type Unspecified