Healthcare Provider Details

I. General information

NPI: 1447374921
Provider Name (Legal Business Name): MALLEPALLI MD A PROFESSIONAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 06/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2408 DUVAL DR STE 2
MONROE LA
71201-2986
US

IV. Provider business mailing address

2408 DUVAL DR STE 2
MONROE LA
71201-2986
US

V. Phone/Fax

Practice location:
  • Phone: 318-388-8561
  • Fax: 318-388-8564
Mailing address:
  • Phone: 318-388-8561
  • Fax: 318-388-8564

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number12443R
License Number StateLA

VIII. Authorized Official

Name: DR. VENKAT N. MALLEPALLI
Title or Position: PRESIDENT
Credential:
Phone: 318-388-8561