1114904166 NPI number — DR. MALLIK R THATIPELLI MD

Table of content: DR. MALLIK R THATIPELLI MD (NPI 1114904166)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114904166 NPI number — DR. MALLIK R THATIPELLI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THATIPELLI
Provider First Name:
MALLIK
Provider Middle Name:
R
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
THATIPELLI
Provider Other First Name:
MALLIKARJUN
Provider Other Middle Name:
R
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1114904166
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
412 WATERVIEW LN NW
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROCHESTER
Provider Business Mailing Address State Name:
MN
Provider Business Mailing Address Postal Code:
55901-8485
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
614-218-1012
Provider Business Mailing Address Fax Number:
952-487-5935

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2808 F ST STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BAKERSFIELD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93301-1833
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
661-873-4216
Provider Business Practice Location Address Fax Number:
661-829-0600
Provider Enumeration Date:
12/29/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  C53592 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 6474639 , issued by the state of ( CA ) . This identifiers is of the category "MEDICAID".




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