Basic Information
| Provider Information | |||||||||
| NPI: | 1609177344 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MUKKAMALA | ||||||||
| FirstName: | MADHU | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Credential: | BS., CNIM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 777 E GIRARD AVE | ||||||||
| Address2: | 250 | ||||||||
| City: | ENGLEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801132767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7202142549 | ||||||||
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| Practice Location | |||||||||
| Address1: | 777 E GIRARD AVE | ||||||||
| Address2: | 250 | ||||||||
| City: | ENGLEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801132767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7202142549 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/11/2010 | ||||||||
| LastUpdateDate: | 11/11/2010 | ||||||||
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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 | 246ZE0600X | 1415 | NC | Y | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other | Electroneurodiagnostic |
No ID Information.