Provider Demographics
NPI:1902857295
Name:MADDUKURI, PRASAD V (MD)
Entity Type:Individual
Prefix:
First Name:PRASAD
Middle Name:V
Last Name:MADDUKURI
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:P.O BOX 850214
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75185-0214
Mailing Address - Country:US
Mailing Address - Phone:214-206-3695
Mailing Address - Fax:866-313-9413
Practice Address - Street 1:341 WHEATFIELD DR
Practice Address - Street 2:SUITE 190
Practice Address - City:SUNNYVALE
Practice Address - State:TX
Practice Address - Zip Code:75182-4638
Practice Address - Country:US
Practice Address - Phone:214-206-3695
Practice Address - Fax:866-313-9413
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-12
Last Update Date:2019-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP2895207RI0011X, 207RC0000X, 207UN0901X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207UN0901XAllopathic & Osteopathic PhysiciansNuclear MedicineNuclear Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXTXB159166OtherMEDICARE
TX303013201Medicaid