Provider Demographics
NPI:1184727141
Name:MADHURAPANTULA, MADHAVI (DO)
Entity type:Individual
Prefix:
First Name:MADHAVI
Middle Name:
Last Name:MADHURAPANTULA
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 N ACADEMY AVE
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:17822-4903
Mailing Address - Country:US
Mailing Address - Phone:570-271-6144
Mailing Address - Fax:570-271-6578
Practice Address - Street 1:25 CHURCH ST
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18765-7701
Practice Address - Country:US
Practice Address - Phone:570-808-3181
Practice Address - Fax:570-808-8935
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-06
Last Update Date:2016-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS018176207Q00000X
NY231385207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY2755535Medicaid
NY35R154L621Medicare PIN
NY35R1518811Medicare PIN