Provider Demographics
NPI:1790872638
Name:MADDALI, RADHIKA (MD)
Entity Type:Individual
Prefix:DR
First Name:RADHIKA
Middle Name:
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 1:310 CENTRAL AVE
Mailing Address - Street 2:SUITE 305
Mailing Address - City:EAST ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07018-2838
Mailing Address - Country:US
Mailing Address - Phone:973-678-2900
Mailing Address - Fax:973-678-8183
Practice Address - Street 1:310 CENTRAL AVE
Practice Address - Street 2:SUITE 305
Practice Address - City:EAST ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07018-2838
Practice Address - Country:US
Practice Address - Phone:973-678-2900
Practice Address - Fax:973-678-8183
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2013-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MAO7474500207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ081474Medicare ID - Type Unspecified
I11850Medicare UPIN