Provider Demographics
NPI:1770660300
Name:GEDDAM, MAMATHA (MD)
Entity Type:Individual
Prefix:DR
First Name:MAMATHA
Middle Name:
Last Name:GEDDAM
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 1:7220 W NATIONAL AVE
Mailing Address - Street 2:
Mailing Address - City:WEST ALLIS
Mailing Address - State:WI
Mailing Address - Zip Code:53214-4734
Mailing Address - Country:US
Mailing Address - Phone:414-257-8500
Mailing Address - Fax:
Practice Address - Street 1:7220 W NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53214-4734
Practice Address - Country:US
Practice Address - Phone:414-257-8500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI50827-20207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL001573000Medicaid
FL146RROtherBLUE CROSS BLUE SHIELD
WI1770660300Medicaid
FLP00811432OtherRAILROAD MEDICARE
WI1770660300Medicaid