Basic Information
| Provider Information | |||||||||
| NPI: | 1598949547 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MALLU | ||||||||
| FirstName: | VENKATA | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1644 BASS RD | ||||||||
| Address2: | APT 1225 | ||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312106505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787417241 | ||||||||
| FaxNumber: | 4787458932 | ||||||||
| Practice Location | |||||||||
| Address1: | 777 HEMLOCK ST | ||||||||
| Address2: | |||||||||
| City: | MACON | ||||||||
| State: | GA | ||||||||
| PostalCode: | 312012102 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4787417241 | ||||||||
| FaxNumber: | 4787458932 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/27/2007 | ||||||||
| LastUpdateDate: | 05/14/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 062252 | GA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 062252 | GA | N | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 586433793 | 05 | GA | MEDICAID |