Provider Demographics
NPI:1851430797
Name:MADDELA, VINCENT JOSEPH (MD)
Entity Type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:JOSEPH
Last Name:MADDELA
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 1:2701 CHESTER AVE
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93301-2016
Mailing Address - Country:US
Mailing Address - Phone:661-716-9422
Mailing Address - Fax:661-323-0889
Practice Address - Street 1:2701 CHESTER AVE # 201
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93301-2016
Practice Address - Country:US
Practice Address - Phone:661-716-1070
Practice Address - Fax:661-716-1075
Is Sole Proprietor?:No
Enumeration Date:2007-02-06
Last Update Date:2013-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA53726207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ01707ZOtherMEDICARE GROUP #
CAGR0092950OtherMEDI-CAL GROUP #
CAZZZ01800ZOtherBLUE SHIELD GROUP PROV #
CAGR0092950OtherMEDI-CAL GROUP #
CAZZZ01800ZOtherBLUE SHIELD GROUP PROV #