Provider Demographics
NPI:1770741944
Name:MADDALA, VAMSILATHA (MD)
Entity type:Individual
Prefix:DR
First Name:VAMSILATHA
Middle Name:
Last Name:MADDALA
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 1:5171 CARRIANA CT
Mailing Address - Street 2:
Mailing Address - City:INVERNESS
Mailing Address - State:IL
Mailing Address - Zip Code:60010-5667
Mailing Address - Country:US
Mailing Address - Phone:847-346-6398
Mailing Address - Fax:
Practice Address - Street 1:5171 CARRIANA CT
Practice Address - Street 2:
Practice Address - City:INVERNESS
Practice Address - State:IL
Practice Address - Zip Code:60010-5667
Practice Address - Country:US
Practice Address - Phone:847-346-6398
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-23
Last Update Date:2023-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036123793208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILFM1567641OtherDEA
IL215188004Medicare PIN
ILP00986414OtherRR MEDICARE PTAN