Healthcare Provider Details

I. General information

NPI: 1790742344
Provider Name (Legal Business Name): RAM GOPAL MALLADI M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2006
Last Update Date: 03/24/2020
Certification Date: 03/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 SPRINGFIELD RD SUITE 6
WESTFIELD MA
01085-1832
US

IV. Provider business mailing address

10 HOSPITAL DR STE 106
HOLYOKE MA
01040-6612
US

V. Phone/Fax

Practice location:
  • Phone: 413-568-2304
  • Fax: 413-568-3517
Mailing address:
  • Phone: 413-568-2304
  • Fax: 413-568-3517

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Y00000X
TaxonomyOtolaryngology Physician
License Number45911
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: