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General NPI Number Information
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NPI Number | 1770733743
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Entity Type | Individual
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Provider Name | MALLIKARJUNA NALLEGOWDA M.D, DNB, MNAMS
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Gender | Male
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Dates
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Enumeration Date | 09/25/2008
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Last Update Date | 03/02/2023
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Provider Practice Location Address
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Address Line | 3676 PARKER BLVD STE 230
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City | PUEBLO
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State | CO
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Zip | 81008-2213
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Country | US
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Telephone | 719-553-2200
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Fax | 833-916-2049
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Provider Business Mailing Address
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Address Line | PO BOX 9000
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City | PUEBLO
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State | CO
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Zip | 81008-9000
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Country | US
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Telephone | 719-557-3666
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Fax | 719-557-3633
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208VP0000X
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Taxonomy Name | Pain Medicine Physician
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License Number | 52039
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License Number State | CO
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