Provider Demographics
NPI:1598949547
Name:MALLU, VENKATA C (MD)
Entity type:Individual
Prefix:
First Name:VENKATA
Middle Name:C
Last Name:MALLU
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 1:101 ROYAL CREST CIR
Mailing Address - Street 2:
Mailing Address - City:KATHLEEN
Mailing Address - State:GA
Mailing Address - Zip Code:31047-2144
Mailing Address - Country:US
Mailing Address - Phone:478-319-5962
Mailing Address - Fax:478-745-8932
Practice Address - Street 1:707 N HOUSTON RD
Practice Address - Street 2:
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31093-2101
Practice Address - Country:US
Practice Address - Phone:478-922-4010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-12-27
Last Update Date:2025-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA062252208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA586433793Medicaid
GA586433793Medicaid