Provider Demographics
NPI:1922450170
Name:PRASAD MADDUKURI MD PLLC
Entity Type:Organization
Organization Name:PRASAD MADDUKURI MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GOVERNING MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:PRASAD
Authorized Official - Middle Name:V
Authorized Official - Last Name:MADDUKURI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:617-319-1958
Mailing Address - Street 1:PO BOX 850214
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75185-0214
Mailing Address - Country:US
Mailing Address - Phone:888-212-4243
Mailing Address - Fax:
Practice Address - Street 1:341 WHEATFIELD DR
Practice Address - Street 2:SUITE 190
Practice Address - City:SUNNYVALE
Practice Address - State:TX
Practice Address - Zip Code:75182-4638
Practice Address - Country:US
Practice Address - Phone:972-686-8200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-11
Last Update Date:2020-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP2895261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty