Provider Demographics
NPI:1821005422
Name:PALLY, MADHAVA T (MD, PA)
Entity type:Individual
Prefix:DR
First Name:MADHAVA
Middle Name:T
Last Name:PALLY
Suffix:
Gender:M
Credentials:MD, PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2316 PATRINOSTRO RD
Mailing Address - Street 2:
Mailing Address - City:PLANT CITY
Mailing Address - State:FL
Mailing Address - Zip Code:33565-7228
Mailing Address - Country:US
Mailing Address - Phone:888-246-0313
Mailing Address - Fax:888-247-1186
Practice Address - Street 1:1520 SLATE CREEK RD STE 205
Practice Address - Street 2:
Practice Address - City:GRUNDY
Practice Address - State:VA
Practice Address - Zip Code:24614-6975
Practice Address - Country:US
Practice Address - Phone:276-935-1640
Practice Address - Fax:606-218-4697
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-03
Last Update Date:2023-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME42506174400000X
KY51263207RC0000X
VA0101263918207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL067609800Medicaid
FLD54052Medicare UPIN
FL067609800Medicaid