Provider Demographics
NPI:1063436715
Name:DUKKIPATI, MADHU (MD)
Entity type:Individual
Prefix:
First Name:MADHU
Middle Name:
Last Name:DUKKIPATI
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19248
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:IL
Mailing Address - Zip Code:62794-9248
Mailing Address - Country:US
Mailing Address - Phone:217-528-7541
Mailing Address - Fax:
Practice Address - Street 1:505 E GRANT ST STE 110
Practice Address - Street 2:
Practice Address - City:MACOMB
Practice Address - State:IL
Practice Address - Zip Code:61455-3308
Practice Address - Country:US
Practice Address - Phone:217-528-7541
Practice Address - Fax:217-525-2535
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2025-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-109161207RC0000X, 207RI0011X, 207RI0011X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00477441OtherRAILROAD
IL086380OtherHEALTH ALLIANCE
IL036109161Medicaid
IL036109161Medicaid
ILP00477441OtherRAILROAD
IL086380OtherHEALTH ALLIANCE