Basic Information
| Provider Information | |||||||||
| NPI: | 1225007917 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MADHAVARAPU | ||||||||
| FirstName: | RAMCHANDER | ||||||||
| MiddleName: | RAO | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2120 EXCHANGE ST | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | ASTORIA | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971033365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033257337 | ||||||||
| FaxNumber: | 5033253706 | ||||||||
| Practice Location | |||||||||
| Address1: | 2120 EXCHANGE ST | ||||||||
| Address2: | SUITE 202 | ||||||||
| City: | ASTORIA | ||||||||
| State: | OR | ||||||||
| PostalCode: | 971033365 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5033257337 | ||||||||
| FaxNumber: | 5033253706 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/15/2006 | ||||||||
| LastUpdateDate: | 07/16/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | MD25214 | OR | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 276048 | 05 | OR | MEDICAID | 1119858 | 05 | WA | MEDICAID |