Provider Demographics
NPI: | 1831473859 |
---|---|
Name: | ANITHA MANDADAPU, MD, PLLC |
Entity Type: | Organization |
Organization Name: | ANITHA MANDADAPU, MD, PLLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | MEMBER |
Authorized Official - Prefix: | |
Authorized Official - First Name: | ANITHA |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | MANDADAPU |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | MD |
Authorized Official - Phone: | 502-817-0927 |
Mailing Address - Street 1: | 3905 SPRING VALLEY WAY |
Mailing Address - Street 2: | |
Mailing Address - City: | LOUISVILLE |
Mailing Address - State: | KY |
Mailing Address - Zip Code: | 40241-5121 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 502-817-0927 |
Mailing Address - Fax: | 502-222-8745 |
Practice Address - Street 1: | 8521 LA GRANGE RD |
Practice Address - Street 2: | |
Practice Address - City: | LOUISVILLE |
Practice Address - State: | KY |
Practice Address - Zip Code: | 40242-3800 |
Practice Address - Country: | US |
Practice Address - Phone: | 502-817-0927 |
Practice Address - Fax: | 502-222-8745 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2011-10-10 |
Last Update Date: | 2011-10-10 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
KY | 42490 | 174400000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 174400000X | Other Service Providers | Specialist | Group - Single Specialty |