Provider Demographics
NPI:1922276112
Name:VUPPALI, MADHAVILATHA (MD)
Entity Type:Individual
Prefix:DR
First Name:MADHAVILATHA
Middle Name:
Last Name:VUPPALI
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 1:200 S RIVERSHIRE DR STE 300
Mailing Address - Street 2:
Mailing Address - City:CONROE
Mailing Address - State:TX
Mailing Address - Zip Code:77304-3485
Mailing Address - Country:US
Mailing Address - Phone:832-610-2822
Mailing Address - Fax:936-777-8831
Practice Address - Street 1:200 S RIVERSHIRE DR STE 300
Practice Address - Street 2:
Practice Address - City:CONROE
Practice Address - State:TX
Practice Address - Zip Code:77304-3485
Practice Address - Country:US
Practice Address - Phone:832-610-2822
Practice Address - Fax:936-777-8831
Is Sole Proprietor?:Yes
Enumeration Date:2008-02-11
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN4825207R00000X, 207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX209330403Medicaid
TXB160671Medicare PIN