Provider Demographics
NPI:1932193653
Name:GADDAM, MADHAVI (MD)
Entity Type:Individual
Prefix:
First Name:MADHAVI
Middle Name:
Last Name:GADDAM
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 1:159 BARNEGAT RD FL 2
Mailing Address - Street 2:
Mailing Address - City:POUGHKEEPSIE
Mailing Address - State:NY
Mailing Address - Zip Code:12601-5401
Mailing Address - Country:US
Mailing Address - Phone:845-452-9800
Mailing Address - Fax:845-452-7691
Practice Address - Street 1:159 BARNEGAT RD FL 2
Practice Address - Street 2:
Practice Address - City:POUGHKEEPSIE
Practice Address - State:NY
Practice Address - Zip Code:12601-5401
Practice Address - Country:US
Practice Address - Phone:845-452-9800
Practice Address - Fax:845-452-7691
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY220330207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02218106Medicaid
NYMG03V69810OtherEMPIRE BLUE CROSS BLUE SHIELD
NY049AD1Medicare ID - Type Unspecified
NY02218106Medicaid
NY049ADJW811Medicare PIN
NY100017149Medicare PIN