Healthcare Provider Details

I. General information

NPI: 1568099166
Provider Name (Legal Business Name): CHAITANYA LAKSHMIDHAR MALLADI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: CHATT MALLADI MD

II. Dates (important events)

Enumeration Date: 03/24/2020
Last Update Date: 07/10/2023
Certification Date: 07/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9434 MEDICAL CENTER DR
LA JOLLA CA
92037-1337
US

IV. Provider business mailing address

9500 GILMAN DRIVE, MAIL CODE 7411
SAN DIEGO CA
92037-7411
US

V. Phone/Fax

Practice location:
  • Phone: 858-657-8530
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA186034
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: