Provider Demographics
NPI:1790825487
Name:MADDALI, SIRISH (MD)
Entity Type:Individual
Prefix:DR
First Name:SIRISH
Middle Name:
Last Name:MADDALI
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 1:244 WESTERN AVENUE
Mailing Address - Street 2:
Mailing Address - City:SOUTH PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04106
Mailing Address - Country:US
Mailing Address - Phone:207-775-3446
Mailing Address - Fax:207-879-1646
Practice Address - Street 1:244 WESTERN AVENUE
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106
Practice Address - Country:US
Practice Address - Phone:207-775-3446
Practice Address - Fax:207-879-1646
Is Sole Proprietor?:No
Enumeration Date:2007-02-08
Last Update Date:2011-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA90979208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH30209881Medicaid
NH30209881Medicaid