Provider Demographics
NPI:1710407689
Name:MADABATTULA, MARKANDEYA
Entity Type:Individual
Prefix:
First Name:MARKANDEYA
Middle Name:
Last Name:MADABATTULA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:624 LEGER WAY
Mailing Address - Street 2:
Mailing Address - City:EDMONTON
Mailing Address - State:ALBERTA
Mailing Address - Zip Code:T6R 0C2
Mailing Address - Country:CA
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1 HOSPITAL DR # DC043.00
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65212-1000
Practice Address - Country:US
Practice Address - Phone:573-884-9066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-22
Last Update Date:2020-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017021066207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine