Provider Demographics
NPI:1134232168
Name:MANDALA, MADHAVI REDDY (MD)
Entity type:Individual
Prefix:
First Name:MADHAVI
Middle Name:REDDY
Last Name:MANDALA
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 1:202 N DIVISION ST STE 301
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98001-4939
Mailing Address - Country:US
Mailing Address - Phone:253-833-7256
Mailing Address - Fax:
Practice Address - Street 1:202 N DIVISION ST STE 301
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98001-4939
Practice Address - Country:US
Practice Address - Phone:253-833-7256
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-16
Last Update Date:2012-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036114994207R00000X
WAMD60253695207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILCA1439OtherRR GROUP NUMBER
ILP00406649OtherRR MEDICARE NUMBER
ILCE9335OtherRR GROUP NUMBER
ILP00393076OtherRR MEDICARE
IL036114994Medicaid
ILCE9335OtherRR GROUP NUMBER