Provider Demographics
NPI:1447374921
Name:MALLEPALLI MD A PROFESSIONAL
Entity type:Organization
Organization Name:MALLEPALLI MD A PROFESSIONAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:VENKAT
Authorized Official - Middle Name:N
Authorized Official - Last Name:MALLEPALLI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:318-388-8561
Mailing Address - Street 1:2408 DUVAL DR STE 2
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-2986
Mailing Address - Country:US
Mailing Address - Phone:318-388-8561
Mailing Address - Fax:318-388-8564
Practice Address - Street 1:2408 DUVAL DR STE 2
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-2986
Practice Address - Country:US
Practice Address - Phone:318-388-8561
Practice Address - Fax:318-388-8564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-19
Last Update Date:2019-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA12443R261QC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1536199Medicaid
LA1536199Medicaid
LA5A379CJ10Medicare ID - Type Unspecified