Healthcare Provider Details

I. General information

NPI: 1083749303
Provider Name (Legal Business Name): MALLIK KALEPU M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 06/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11439 SUTPHIN BLVD
JAMAICA NY
11434-1022
US

IV. Provider business mailing address

8053 255TH ST
FLORAL PARK NY
11004-1215
US

V. Phone/Fax

Practice location:
  • Phone: 718-945-7150
  • Fax: 718-945-2596
Mailing address:
  • Phone: 718-558-7160
  • Fax: 718-322-6152

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number205718
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: