1376600759 NPI number — DR. KRISHNA PRASAD MADIRAJU M.D.FAAP

Table of content: JENNIFER LUSTMAN LCSW (NPI 1710154158)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376600759 NPI number — DR. KRISHNA PRASAD MADIRAJU M.D.FAAP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MADIRAJU
Provider First Name:
KRISHNA
Provider Middle Name:
PRASAD
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
M.D.FAAP
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1376600759
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/07/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
22445 CONSERVANCY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ASHBURN
Provider Business Mailing Address State Name:
VA
Provider Business Mailing Address Postal Code:
20148-8068
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
703-899-7593
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2024 OPITZ BLVD STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOODBRIDGE
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
22191-3388
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
703-492-7000
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
01/03/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208000000X , with the licence number:  0101054958 , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 010236568 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5686693 . This is a "AETNA" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 897801 . This is a "ALLIANCE PPO" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".
  • Identifier: 006720421 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 006739491 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 259327 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 368437 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 98446 . This is a "AMERIGROUP" identifier , issued by the state of ( VA ) . This identifiers is of the category "OTHER".




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