Healthcare Provider Details

I. General information

NPI: 1659478527
Provider Name (Legal Business Name): INFECTIOUS DISEASE DOCTORS OF NEVADA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2006
Last Update Date: 04/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4445 MAGNOLIA AVE
RIVERSIDE CA
92501-4135
US

IV. Provider business mailing address

3022 S DURANGO DR SUITE 100
LAS VEGAS NV
89117-4439
US

V. Phone/Fax

Practice location:
  • Phone: 951-788-3000
  • Fax:
Mailing address:
  • Phone: 702-256-3637
  • Fax: 702-256-3307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number9640
License Number StateNV

VIII. Authorized Official

Name: SUDHAKAR V. MALLELA
Title or Position: PRESIDENT
Credential: M.D.
Phone: 702-878-3235