Provider Demographics
NPI:1740337930
Name:YAKKANTI, MADHUSUDHAN R (MD)
Entity type:Individual
Prefix:
First Name:MADHUSUDHAN
Middle Name:R
Last Name:YAKKANTI
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:PO BOX 909
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40201-0909
Mailing Address - Country:US
Mailing Address - Phone:502-588-0328
Mailing Address - Fax:
Practice Address - Street 1:3920 DUTCHMANS LN STE 310
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4702
Practice Address - Country:US
Practice Address - Phone:502-259-6888
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-03
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01075275A207XX0801X, 207X00000X, 207XS0114X
KY40767207XX0801X, 207X00000X, 207XS0114X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0801XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryOrthopaedic Trauma
No207XS0114XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryAdult Reconstructive Orthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200870310Medicaid
KY50015260OtherPASSPORT
KY2851482000OtherPASSPORT ADVANTAGE
KY7100003910Medicaid
KY7492940OtherAETNA
P00399786OtherRAIL ROAD MEDICARE
KY000000516385OtherANTHEM
KYP200468583OtherRAILROAD MEDICARE UL
KY7100003910Medicaid
KY1367910Medicare PIN
KY2851482000OtherPASSPORT ADVANTAGE
KY000000516385OtherANTHEM