Provider Demographics
NPI:1588699763
Name:MADDALI, VANI (MD)
Entity type:Individual
Prefix:
First Name:VANI
Middle Name:
Last Name:MADDALI
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 1:22 OLD SHORT HILLS RD
Mailing Address - Street 2:STE 104
Mailing Address - City:LIVINGSTON
Mailing Address - State:NJ
Mailing Address - Zip Code:07039-5604
Mailing Address - Country:US
Mailing Address - Phone:973-535-9682
Mailing Address - Fax:973-535-3406
Practice Address - Street 1:22 OLD SHORT HILLS RD
Practice Address - Street 2:STE 104
Practice Address - City:LIVINGSTON
Practice Address - State:NJ
Practice Address - Zip Code:07039-5604
Practice Address - Country:US
Practice Address - Phone:973-535-9682
Practice Address - Fax:973-535-3406
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2012-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA07029100207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ8522600Medicaid
NJ8522600Medicaid
NJ046666Medicare ID - Type Unspecified