Provider Demographics
NPI:1427158435
Name:HARIBABU, MUDDANA (MD)
Entity type:Individual
Prefix:DR
First Name:MUDDANA
Middle Name:
Last Name:HARIBABU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 WINTHROP ST
Mailing Address - Street 2:
Mailing Address - City:WORCESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01604-4435
Mailing Address - Country:US
Mailing Address - Phone:508-753-2240
Mailing Address - Fax:508-753-3990
Practice Address - Street 1:10 WINTHROP ST
Practice Address - Street 2:SUITE#319
Practice Address - City:WORCESTER
Practice Address - State:MA
Practice Address - Zip Code:01604-4435
Practice Address - Country:US
Practice Address - Phone:508-753-2240
Practice Address - Fax:508-753-3990
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA42995208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2064332Medicaid
MAD88507Medicare UPIN