Provider Demographics
NPI:1902911837
Name:KALAKOTA, MADHUSUDANA (MD)
Entity Type:Individual
Prefix:
First Name:MADHUSUDANA
Middle Name:
Last Name:KALAKOTA
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 1:1920 N CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:KISSIMMEE
Mailing Address - State:FL
Mailing Address - Zip Code:34741-2331
Mailing Address - Country:US
Mailing Address - Phone:407-931-2991
Mailing Address - Fax:407-933-4699
Practice Address - Street 1:1920 NORTH CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:KISSIMMEE
Practice Address - State:FL
Practice Address - Zip Code:34741-2373
Practice Address - Country:US
Practice Address - Phone:407-931-2991
Practice Address - Fax:407-933-4699
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0061078174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL593368006OtherTAX ID
FL370719900Medicaid
FLME0061078OtherMEDICAL LICENSE
FLME0061078OtherMEDICAL LICENSE
FL17758Medicare ID - Type Unspecified
FLE48836Medicare UPIN