1568099166 NPI number — CHAITANYA LAKSHMIDHAR MALLADI MD

Table of content: CHAITANYA LAKSHMIDHAR MALLADI MD (NPI 1568099166)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1568099166 NPI number — CHAITANYA LAKSHMIDHAR MALLADI MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MALLADI
Provider First Name:
CHAITANYA
Provider Middle Name:
LAKSHMIDHAR
Provider Name Prefix Text:
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:
MALLADI
Provider Other First Name:
CHATT
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1568099166
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/10/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9500 GILMAN DRIVE, MAIL CODE 7411
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92037-7411
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9434 MEDICAL CENTER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LA JOLLA
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92037-1337
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-657-8530
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
03/24/2020

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: 390200000X , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: A186034 , 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)





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