Provider Demographics
NPI:1770983272
Name:ADUMALA, PRADEEP (MD)
Entity type:Individual
Prefix:
First Name:PRADEEP
Middle Name:
Last Name:ADUMALA
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 1:2100 MACK BLVD
Mailing Address - Street 2:
Mailing Address - City:ALLENTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18103-5622
Mailing Address - Country:US
Mailing Address - Phone:707-902-3915
Mailing Address - Fax:
Practice Address - Street 1:314 SOUTH MAIN STREET
Practice Address - Street 2:
Practice Address - City:CONYNGHAM,
Practice Address - State:OR
Practice Address - Zip Code:18219-0395
Practice Address - Country:US
Practice Address - Phone:570-708-1500
Practice Address - Fax:570-708-1501
Is Sole Proprietor?:No
Enumeration Date:2014-09-03
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD468261208000000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA103660812-0001Medicaid
NJ0415502Medicaid