=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114904166
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MALLIK R THATIPELLI MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/29/2005
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2808 F ST STE A
-----------------------------------------------------
City | BAKERSFIELD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93301-1833
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-873-4216
-----------------------------------------------------
Fax | 661-829-0600
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 412 WATERVIEW LN NW
-----------------------------------------------------
City | ROCHESTER
-----------------------------------------------------
State | MN
-----------------------------------------------------
Zip | 55901-8485
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 614-218-1012
-----------------------------------------------------
Fax | 952-487-5935
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RC0000X
-----------------------------------------------------
Taxonomy Name | Cardiovascular Disease Physician
-----------------------------------------------------
License Number | C53592
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------