1114101904 NPI number — CHAITHANYA MALLIKARJUN MD

Table of content: CHAITHANYA MALLIKARJUN MD (NPI 1114101904)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114101904 NPI number — CHAITHANYA MALLIKARJUN MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MALLIKARJUN
Provider First Name:
CHAITHANYA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114101904
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/20/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
19284 STONE OAK PKWY
Provider Second Line Business Mailing Address:
104
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78258-3473
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-598-4730
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19284 STONE OAK PKWY
Provider Second Line Business Practice Location Address:
104
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78258-3473
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-268-0124
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/28/2007

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: 207RI0008X , with the licence number:  MD.201765 , registered in the state of LA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RG0100X , with the licence number: P9220 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1027324 , issued by the state of ( LA ) . This identifiers is of the category "MEDICAID".




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