Healthcare Provider Details

I. General information

NPI: 1598949547
Provider Name (Legal Business Name): VENKATA C MALLU M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/27/2007
Last Update Date: 09/08/2025
Certification Date: 09/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

707 N HOUSTON RD
WARNER ROBINS GA
31093-2101
US

IV. Provider business mailing address

101 ROYAL CREST CIR
KATHLEEN GA
31047-2144
US

V. Phone/Fax

Practice location:
  • Phone: 478-922-4010
  • Fax:
Mailing address:
  • Phone: 478-319-5962
  • Fax: 478-745-8932

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number062252
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number062252
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: