MEDICARE: VIJAYA L MALLELA 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	J6836	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	88Y325	OTHER	TX	BCBS
2	134643901	OTHER	TX	CSHCN
3	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1154354587
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VIJAYA L MALLELA M.D.

Provider Business Mailing Address
First Line	:	4755 ALDINE MAIL ROUTE RD
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77039-5934
Country	:	US
Telephone Number	:	281-985-7600
Fax Number	:	281-985-7620

Provider Business Practice Location Address
First Line	:	4755 ALDINE MAIL RD
Second Line	:
City	:	HOUSTON
State	:	TX
Zip	:	77039-5934
Country	:	US
Telephone Number	:	281-985-7600
Fax Number	:	281-985-7607

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

Provider Enumeration Date	:	07/09/2006
Last Update Date	:	12/18/2023

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