Provider Demographics
NPI:1184978793
Name:MADHYASTHA, MYTHILI LAKSHMI (MSED)
Entity type:Individual
Prefix:MISS
First Name:MYTHILI
Middle Name:LAKSHMI
Last Name:MADHYASTHA
Suffix:
Gender:F
Credentials:MSED
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 STEWART ST FL 2
Mailing Address - Street 2:
Mailing Address - City:AMSTERDAM
Mailing Address - State:NY
Mailing Address - Zip Code:12010-2318
Mailing Address - Country:US
Mailing Address - Phone:518-705-3160
Mailing Address - Fax:
Practice Address - Street 1:623 NEW LOUDON RD
Practice Address - Street 2:
Practice Address - City:LATHAM
Practice Address - State:NY
Practice Address - Zip Code:12110-4031
Practice Address - Country:US
Practice Address - Phone:518-782-1178
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-11-05
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY305240091174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist