Basic Information
| Provider Information | |||||||||
| NPI: | 1164529293 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | BANDA | ||||||||
| FirstName: | MADHUSUDHAN | ||||||||
| MiddleName: | REDDY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1580 SANTA BARBARA BLVD | ||||||||
| Address2: | |||||||||
| City: | THE VILLAGES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321596827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522592159 | ||||||||
| FaxNumber: | 3522595731 | ||||||||
| Practice Location | |||||||||
| Address1: | 1580 SANTA BARBARA BLVD | ||||||||
| Address2: | |||||||||
| City: | THE VILLAGES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 321596827 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3522592159 | ||||||||
| FaxNumber: | 3522595731 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/20/2006 | ||||||||
| LastUpdateDate: | 01/02/2017 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RE0101X | ME96957 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | 277031800 | 05 | FL | MEDICAID | 56688 | 01 | FL | BCBS | OTHER |