Provider Demographics
NPI:1093101511
Name:SAMALA, MALIKARJUN (MD)
Entity Type:Individual
Prefix:
First Name:MALIKARJUN
Middle Name:
Last Name:SAMALA
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 1:501 REDMOND RD NW
Mailing Address - Street 2:
Mailing Address - City:ROME
Mailing Address - State:GA
Mailing Address - Zip Code:30165-1415
Mailing Address - Country:US
Mailing Address - Phone:706-291-0291
Mailing Address - Fax:
Practice Address - Street 1:4864 JACKSON ST
Practice Address - Street 2:FAMILY MEDICINE
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71202
Practice Address - Country:US
Practice Address - Phone:318-330-7600
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-10
Last Update Date:2018-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1093101511207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty