Basic Information
| Provider Information | |||||||||
| NPI: | 1518411636 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SUDHAKAR VENKATA MALLELA MD INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6885 BROCKTON AVE | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925063811 | ||||||||
| CountryCode: | US | ||||||||
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| Address1: | 6885 BROCKTON AVE | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925063811 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7022563637 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 08/05/2016 | ||||||||
| LastUpdateDate: | 07/17/2018 | ||||||||
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| AuthorizedOfficialLastName: | MALLELA | ||||||||
| AuthorizedOfficialFirstName: | SUDHAKAR | ||||||||
| AuthorizedOfficialMiddleName: | VENKATA | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 7022563637 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207RI0200X | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine | Infectious Disease |
No ID Information.