Provider Demographics
NPI:1003019647
Name:MULAMALLA, SUMANTH (MD)
Entity Type:Individual
Prefix:DR
First Name:SUMANTH
Middle Name:
Last Name:MULAMALLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 S DESPLAINES ST
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60661-5500
Mailing Address - Country:US
Mailing Address - Phone:312-654-2700
Mailing Address - Fax:312-654-9930
Practice Address - Street 1:15900 W 101ST AVE
Practice Address - Street 2:
Practice Address - City:DYER
Practice Address - State:IN
Practice Address - Zip Code:46311-3065
Practice Address - Country:US
Practice Address - Phone:219-365-6333
Practice Address - Fax:219-365-8291
Is Sole Proprietor?:No
Enumeration Date:2007-06-11
Last Update Date:2016-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01065980A207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201121060AMedicaid
ILF400289465OtherIL MEDICARE PTAN