Provider Demographics
NPI:1114379534
Name:MALLADI, AJAYCHANDRA REDDY (MD)
Entity Type:Individual
Prefix:
First Name:AJAYCHANDRA REDDY
Middle Name:
Last Name:MALLADI
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 1:44405 WOODWARD AVE
Mailing Address - Street 2:H-23
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48341-5023
Mailing Address - Country:US
Mailing Address - Phone:248-858-6233
Mailing Address - Fax:248-858-3244
Practice Address - Street 1:2300 N 14TH AVE STE 104
Practice Address - Street 2:
Practice Address - City:DODGE CITY
Practice Address - State:KS
Practice Address - Zip Code:67801-2367
Practice Address - Country:US
Practice Address - Phone:620-371-7010
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-07-09
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301109524207R00000X
KS04-41883207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine