Healthcare Provider Details

I. General information

NPI: 1316989197
Provider Name (Legal Business Name): MALATHI TADAKAMALLA M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/13/2006
Last Update Date: 05/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 NE MEADOWVIEW DR
LEES SUMMIT MO
64064-1983
US

IV. Provider business mailing address

PO BOX 219209
KANSAS CITY MO
64121-9209
US

V. Phone/Fax

Practice location:
  • Phone: 913-226-7332
  • Fax: 913-674-5563
Mailing address:
  • Phone: 913-226-7332
  • Fax: 913-674-5563

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License Number2009003023
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: