MEDICARE: DR. MALLIK KALEPU M.D

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	205718	NY

General Provider Information

NPI Number	:	1083749303
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MALLIK KALEPU M.D

Provider Business Mailing Address
First Line	:	8053 255TH ST
Second Line	:
City	:	FLORAL PARK
State	:	NY
Zip	:	11004-1215
Country	:	US
Telephone Number	:	718-558-7160
Fax Number	:	718-322-6152

Provider Business Practice Location Address
First Line	:	11439 SUTPHIN BLVD
Second Line	:
City	:	JAMAICA
State	:	NY
Zip	:	11434-1022
Country	:	US
Telephone Number	:	718-945-7150
Fax Number	:	718-945-2596

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/23/2007
Last Update Date	:	06/25/2013

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