Provider Demographics
NPI:1821009838
Name:LALL, MADHULIKA (MD)
Entity Type:Individual
Prefix:
First Name:MADHULIKA
Middle Name:
Last Name:LALL
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 1:420 E DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:FOND DU LAC
Mailing Address - State:WI
Mailing Address - Zip Code:54935-4560
Mailing Address - Country:US
Mailing Address - Phone:920-926-8340
Mailing Address - Fax:920-926-8370
Practice Address - Street 1:430 E DIVISION ST
Practice Address - Street 2:
Practice Address - City:FOND DU LAC
Practice Address - State:WI
Practice Address - Zip Code:54935-4560
Practice Address - Country:US
Practice Address - Phone:920-926-8332
Practice Address - Fax:920-926-8370
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2023-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101235949208M00000X
WI60163208M00000X
MDD0087838207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
146132OtherANTHEM/BCBS
310269OtherSOUTHERN HEALTH
WV3810000340OtherWV MEDICAID
VA1821009838Medicaid
9309526OtherCIGNA
VA1000870001OtherDME PROVIDER
VA010086272Medicaid
P00193964OtherRAILROAD MEDICARE
VA79389OtherOPTIMA
I14040Medicare UPIN
VAVVB719AMedicare PIN
9309526OtherCIGNA
VA79389OtherOPTIMA
VA005192R54Medicare PIN