Basic Information
| Provider Information | |||||||||
| NPI: | 1861620007 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOLAKATALLA | ||||||||
| FirstName: | PHANI | ||||||||
| MiddleName: | KISHORE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 250 GREEN ST | ||||||||
| Address2: | SUITE 209 | ||||||||
| City: | GARDNER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 014401396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9786695522 | ||||||||
| FaxNumber: | 9786320516 | ||||||||
| Practice Location | |||||||||
| Address1: | 250 GREEN ST | ||||||||
| Address2: | SUITE 209 | ||||||||
| City: | GARDNER | ||||||||
| State: | MA | ||||||||
| PostalCode: | 014401396 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9786695522 | ||||||||
| FaxNumber: | 9786320516 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/25/2009 | ||||||||
| LastUpdateDate: | 07/07/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | MD447302 | PA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 390200000X | MT194411 | PA | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207RG0100X | 261931 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Gastroenterology |
No ID Information.