Provider Demographics
NPI:1134564859
Name:MADALA, SRAVANTHI (MD)
Entity type:Individual
Prefix:
First Name:SRAVANTHI
Middle Name:
Last Name:MADALA
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 1:21 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:MAYNARD
Mailing Address - State:MA
Mailing Address - Zip Code:01754-2505
Mailing Address - Country:US
Mailing Address - Phone:978-287-8520
Mailing Address - Fax:
Practice Address - Street 1:21 MAIN ST
Practice Address - Street 2:
Practice Address - City:MAYNARD
Practice Address - State:MA
Practice Address - Zip Code:01754-2505
Practice Address - Country:US
Practice Address - Phone:978-287-8520
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-05-08
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RILP03596207RE0101X
390200000X
MA277679207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program