Provider Demographics
NPI:1144266065
Name:MADUGULA, MADHAVI (MD)
Entity type:Individual
Prefix:DR
First Name:MADHAVI
Middle Name:
Last Name:MADUGULA
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 1:4501 SAND CREEK RD
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:CA
Mailing Address - Zip Code:94531-8687
Mailing Address - Country:US
Mailing Address - Phone:810-964-3246
Mailing Address - Fax:
Practice Address - Street 1:2200 FORT JESSE RD
Practice Address - Street 2:SUITE 110
Practice Address - City:NORMAL
Practice Address - State:IL
Practice Address - Zip Code:61761-6286
Practice Address - Country:US
Practice Address - Phone:309-661-6290
Practice Address - Fax:309-451-1354
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301085702207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00690231OtherRR MEDICARE INDIVIDUAL #
CA2264OtherRR GROUP #
IL036121987Medicaid
MI4769673Medicaid
IL833120OtherMEDICARE GROUP
IL833120003Medicare PIN