Basic Information
| Provider Information | |||||||||
| NPI: | 1477667814 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | PAMULAPATI | ||||||||
| FirstName: | MALATI | ||||||||
| MiddleName: | V | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8674 1230 E. MAIN STREET | ||||||||
| Address2: | MANKATO CLINIC, LTD | ||||||||
| City: | MANKATO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560028674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5076251811 | ||||||||
| FaxNumber: | 5072316376 | ||||||||
| Practice Location | |||||||||
| Address1: | 1230 E. MAIN STREET | ||||||||
| Address2: | MANKATO CLINIC @ MAIN STREET | ||||||||
| City: | MANKATO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560028674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5076251811 | ||||||||
| FaxNumber: | 5072316376 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/19/2006 | ||||||||
| LastUpdateDate: | 07/15/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/15/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207QG0300X | 49206 | MN | N | Allopathic & Osteopathic Physicians | Family Medicine | Geriatric Medicine | 207Q00000X | 49206 | MN | Y | Allopathic & Osteopathic Physicians | Family Medicine | 174400000X | 31199 | IA | N | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 1111435 | 05 | IA | MEDICAID |