Basic Information
| Provider Information | |||||||||
| NPI: | 1639301328 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JAKKULA | ||||||||
| FirstName: | MADHAVI | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JAKKULA | ||||||||
| OtherFirstName: | MADHAVI | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | MRS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 2 | ||||||||
| Mailing Information | |||||||||
| Address1: | 9400 TUKEY LAKE RD | ||||||||
| Address2: | MP 452 | ||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3218435500 | ||||||||
| FaxNumber: | 3218435550 | ||||||||
| Practice Location | |||||||||
| Address1: | 9400 TUKEY LAKE RD | ||||||||
| Address2: | MP 452 | ||||||||
| City: | ORLANDO | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32819 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3218435500 | ||||||||
| FaxNumber: | 3218435550 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/14/2009 | ||||||||
| LastUpdateDate: | 11/16/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | Y | ||||||||
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| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | ME113523 | FL | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | ME113523 | FL | N | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 005984700 | 05 | FL | MEDICAID | ME113523 | 01 | FL | MEDICAL LICENSE | OTHER |