Basic Information
| Provider Information | |||||||||
| NPI: | 1750543088 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MADDELA | ||||||||
| FirstName: | RICARDO | ||||||||
| MiddleName: | ANDAYA | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | III | ||||||||
| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 638706 | ||||||||
| Address2: | |||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 452638706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708277558 | ||||||||
| FaxNumber: | 2708277530 | ||||||||
| Practice Location | |||||||||
| Address1: | 110 3RD ST | ||||||||
| Address2: | SUITE 130 | ||||||||
| City: | HENDERSON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 424202993 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2708309973 | ||||||||
| FaxNumber: | 2708309975 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2008 | ||||||||
| LastUpdateDate: | 12/05/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 03288 | KY | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 7100152020 | 05 | KY | MEDICAID | 000000700445 | 01 | KY | ANTHEM | OTHER |