Provider Demographics
NPI:1114101904
Name:MALLIKARJUN, CHAITHANYA (MD)
Entity Type:Individual
Prefix:
First Name:CHAITHANYA
Middle Name:
Last Name:MALLIKARJUN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19284 STONE OAK PKWY
Mailing Address - Street 2:104
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78258-3473
Mailing Address - Country:US
Mailing Address - Phone:210-598-4730
Mailing Address - Fax:
Practice Address - Street 1:19284 STONE OAK PKWY
Practice Address - Street 2:104
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78258-3473
Practice Address - Country:US
Practice Address - Phone:210-268-0124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-12-28
Last Update Date:2014-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD.201765207RI0008X
TXP9220207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207RI0008XAllopathic & Osteopathic PhysiciansInternal MedicineHepatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1027324Medicaid
LA1027324Medicaid
LA4K939Medicare PIN
TX367720YQE5Medicare PIN