Provider Demographics
NPI:1174721971
Name:MALATSE, KGATALE SIKO
Entity type:Individual
Prefix:MR
First Name:KGATALE
Middle Name:SIKO
Last Name:MALATSE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6013 BELLE ISLE LN
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46835-1263
Mailing Address - Country:US
Mailing Address - Phone:260-492-6420
Mailing Address - Fax:
Practice Address - Street 1:3811 PARNELL AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-1409
Practice Address - Country:US
Practice Address - Phone:260-482-4651
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100266090Medicaid