Provider Demographics
NPI:1093996233
Name:MALLIKARJUNAPPA, UNKNOWN (MD)
Entity Type:Individual
Prefix:
First Name:UNKNOWN
Middle Name:
Last Name:MALLIKARJUNAPPA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MALLIKARJUNAPPA
Other - Middle Name:
Other - Last Name:MK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:633 GOV CARLOS CAMACHO ROAD SUITE 210
Mailing Address - Street 2:
Mailing Address - City:TAMUNING
Mailing Address - State:GU
Mailing Address - Zip Code:96913
Mailing Address - Country:US
Mailing Address - Phone:671-649-1001
Mailing Address - Fax:
Practice Address - Street 1:633 GOV CARLOS CAMACHO ROAD SUITE 210
Practice Address - Street 2:
Practice Address - City:TAMUNING
Practice Address - State:GU
Practice Address - Zip Code:96913
Practice Address - Country:US
Practice Address - Phone:671-649-1001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-11-15
Last Update Date:2019-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GUM-18582085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program