Healthcare Provider Details

I. General information

NPI: 1336279801
Provider Name (Legal Business Name): MALAVALLI SEETHARAM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: MALAVALLI SEETHARAM MD

II. Dates (important events)

Enumeration Date: 03/06/2007
Last Update Date: 02/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1524 MCHENRY AVE SUITE 570
MODESTO CA
95350-4500
US

IV. Provider business mailing address

1524 MCHENRY AVE SUITE 570
MODESTO CA
95350-4500
US

V. Phone/Fax

Practice location:
  • Phone: 209-572-3880
  • Fax: 209-572-3349
Mailing address:
  • Phone: 209-572-3880
  • Fax: 209-572-3349

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License Number199169
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: