Healthcare Provider Details

I. General information

NPI: 1043873607
Provider Name (Legal Business Name): VENKAT PRAJWAL NAIDU MALLARAPU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2019
Last Update Date: 05/04/2023
Certification Date: 05/04/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD
GAINESVILLE FL
32610-3003
US

IV. Provider business mailing address

PO BOX 100238
GAINESVILLE FL
32610-0238
US

V. Phone/Fax

Practice location:
  • Phone: 352-294-8278
  • Fax: 352-265-0379
Mailing address:
  • Phone: 352-294-8278
  • Fax: 352-265-0379

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberME162261
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME162261
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: