Healthcare Provider Details

I. General information

NPI: 1053975250
Provider Name (Legal Business Name): PRIYA MALLIKARJUNA MD, MA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2019
Last Update Date: 12/29/2025
Certification Date: 12/29/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 PARSONS BLVD PEDIATRICS DEPARTMENT ROOM 410 1982 BUILDING
FLUSHING NY
11355
US

IV. Provider business mailing address

2 BEL AIR CT
OYSTER BAY NY
11771-4409
US

V. Phone/Fax

Practice location:
  • Phone: 516-972-8109
  • Fax:
Mailing address:
  • Phone: 516-972-8109
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0208X
TaxonomyPediatric Infectious Diseases Physician
License Number318067
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: