Healthcare Provider Details

I. General information

NPI: 1649273715
Provider Name (Legal Business Name): CHRISTOPHER T MALLAVARAPU MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2005
Last Update Date: 07/24/2024
Certification Date: 07/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 MAIN ST
OLEAN NY
14760-1513
US

IV. Provider business mailing address

86 NAVESINK AVE
RUMSON NJ
07760-2043
US

V. Phone/Fax

Practice location:
  • Phone: 716-373-2600
  • Fax:
Mailing address:
  • Phone: 337-296-8523
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207UN0901X
TaxonomyNuclear Cardiology Physician
License Number183914
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number183914
License Number StateNY

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier130730000068
Identifier TypeOTHER
Identifier StateNY
Identifier IssuerFIDELIS
# 2
Identifier01365920
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer
# 3
Identifier3997380
Identifier TypeOTHER
Identifier StateNY
Identifier IssuerEMBLEM HEALTH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: