Provider Demographics
NPI:1740621481
Name:IDAMAKANTI, MURALIDHAR REDDY (MD)
Entity type:Individual
Prefix:
First Name:MURALIDHAR
Middle Name:REDDY
Last Name:IDAMAKANTI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 26666
Mailing Address - Street 2:PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-6770
Mailing Address - Fax:
Practice Address - Street 1:4422 3RD AVE
Practice Address - Street 2:DEPT OF INTERNAL MED
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-2545
Practice Address - Country:US
Practice Address - Phone:718-960-6202
Practice Address - Fax:718-960-3486
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-10
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY288072207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty