Provider Demographics
NPI:1588663843
Name:MADAMALA, THAKSHAKAMANI (MD)
Entity type:Individual
Prefix:
First Name:THAKSHAKAMANI
Middle Name:
Last Name:MADAMALA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 COVENTRY LN
Mailing Address - Street 2:SUITE 205
Mailing Address - City:CRYSTAL LAKE
Mailing Address - State:IL
Mailing Address - Zip Code:60014-7579
Mailing Address - Country:US
Mailing Address - Phone:815-455-7100
Mailing Address - Fax:815-455-3951
Practice Address - Street 1:500 COVENTRY LN
Practice Address - Street 2:SUITE 205
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-7579
Practice Address - Country:US
Practice Address - Phone:815-455-7100
Practice Address - Fax:815-455-3951
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2012-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-0858072084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036085807Medicaid
IL036085807Medicaid
ILF58854Medicare UPIN