Provider Demographics
NPI:1952494874
Name:KANDALA, MADHURI
Entity Type:Individual
Prefix:
First Name:MADHURI
Middle Name:
Last Name:KANDALA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1370 116TH AVE NE
Mailing Address - Street 2:SUITE 209
Mailing Address - City:BELLEVUE
Mailing Address - State:WA
Mailing Address - Zip Code:98004-3825
Mailing Address - Country:US
Mailing Address - Phone:425-453-8406
Mailing Address - Fax:425-453-4173
Practice Address - Street 1:1370 116TH AVE NE
Practice Address - Street 2:SUITE 209
Practice Address - City:BELLEVUE
Practice Address - State:WA
Practice Address - Zip Code:98004-3825
Practice Address - Country:US
Practice Address - Phone:425-453-8406
Practice Address - Fax:425-453-4173
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-02
Last Update Date:2019-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD00042273207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA1123520Medicaid
WAH94918Medicare UPIN
WAG8864126Medicare PIN
WAAB39476Medicare ID - Type Unspecified