Provider Demographics
NPI:1770512774
Name:MADDUKURI, VINAYA CHANDRA (MD)
Entity Type:Individual
Prefix:
First Name:VINAYA
Middle Name:CHANDRA
Last Name:MADDUKURI
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:PO BOX 601372
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1372
Mailing Address - Country:US
Mailing Address - Phone:704-446-1242
Mailing Address - Fax:704-446-1241
Practice Address - Street 1:1350 S KINGS DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-2134
Practice Address - Country:US
Practice Address - Phone:704-446-1242
Practice Address - Fax:704-446-1241
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2016-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36114942207R00000X
OH35.088133207R00000X
NC2011-00258207R00000X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5920649Medicaid
KY64127996Medicaid
NC1770512774Medicaid
OH2697121Medicaid
TN4047833Medicaid
SCNC1630Medicaid
IN200844300Medicaid
NCNC7213BMedicare PIN
NCNC7213AMedicare PIN
NC1770512774Medicaid