Provider Demographics
NPI:1528109758
Name:UPRETY, MADAN (MD)
Entity type:Individual
Prefix:
First Name:MADAN
Middle Name:
Last Name:UPRETY
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 1:12359 SUNRISE VALLEY DR STE 320
Mailing Address - Street 2:
Mailing Address - City:RESTON
Mailing Address - State:VA
Mailing Address - Zip Code:20191-3463
Mailing Address - Country:US
Mailing Address - Phone:703-596-4796
Mailing Address - Fax:
Practice Address - Street 1:12359 SUNRISE VALLEY DR STE 320
Practice Address - Street 2:
Practice Address - City:RESTON
Practice Address - State:VA
Practice Address - Zip Code:20191-3463
Practice Address - Country:US
Practice Address - Phone:703-596-4796
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-09
Last Update Date:2022-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD00684012084P0800X
WI481442084P0800X
VA01012469302084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34667100Medicaid
WI004500493Medicare ID - Type Unspecified
WI34667100Medicaid