Provider Demographics
NPI:1760057632
Name:SURESH, MALAVIKA (MD, MB BCH BAO)
Entity type:Individual
Prefix:MS
First Name:MALAVIKA
Middle Name:
Last Name:SURESH
Suffix:
Gender:F
Credentials:MD, MB BCH BAO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1233 E 2ND ST
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82601-2926
Mailing Address - Country:US
Mailing Address - Phone:800-822-7201
Mailing Address - Fax:
Practice Address - Street 1:1233 E 2ND ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82601-2926
Practice Address - Country:US
Practice Address - Phone:800-822-7201
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-24
Last Update Date:2025-10-22
Deactivation Date:2022-11-14
Deactivation Code:
Reactivation Date:2024-03-11
Provider Licenses
StateLicense IDTaxonomies
WY17329A207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine