Provider Demographics
NPI:1376685065
Name:DHARAWAT, MADHUSUDAN N (MD)
Entity type:Individual
Prefix:DR
First Name:MADHUSUDAN
Middle Name:N
Last Name:DHARAWAT
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 1:3523 BLUELAKE CIR
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95219-1745
Mailing Address - Country:US
Mailing Address - Phone:304-215-2490
Mailing Address - Fax:
Practice Address - Street 1:3523 BLUELAKE CIR
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95219-1745
Practice Address - Country:US
Practice Address - Phone:304-215-2490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-12
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV21010207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV2003824000Medicaid
WV2003824000Medicaid
WVA96-557Medicare UPIN