Provider Demographics
NPI:1972516136
Name:VALLALA, MADHUSUDAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MADHUSUDAN
Middle Name:
Last Name:VALLALA
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 1:2 SAINT ANTHONYS WAY
Mailing Address - Street 2:SUITE 205
Mailing Address - City:ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62002-4569
Mailing Address - Country:US
Mailing Address - Phone:618-462-2222
Mailing Address - Fax:618-463-5004
Practice Address - Street 1:2 SAINT ANTHONYS WAY
Practice Address - Street 2:SUITE 205
Practice Address - City:ALTON
Practice Address - State:IL
Practice Address - Zip Code:62002-4569
Practice Address - Country:US
Practice Address - Phone:618-462-2222
Practice Address - Fax:618-463-5004
Is Sole Proprietor?:No
Enumeration Date:2006-08-15
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036053208207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036053208Medicaid
IL036053208Medicaid
IL218920Medicare ID - Type Unspecified
IL036053208Medicaid