Provider Demographics
NPI:1114904166
Name:THATIPELLI, MALLIK R (MD)
Entity Type:Individual
Prefix:DR
First Name:MALLIK
Middle Name:R
Last Name:THATIPELLI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MALLIKARJUN
Other - Middle Name:R
Other - Last Name:THATIPELLI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:412 WATERVIEW LN NW
Mailing Address - Street 2:
Mailing Address - City:ROCHESTER
Mailing Address - State:MN
Mailing Address - Zip Code:55901-8485
Mailing Address - Country:US
Mailing Address - Phone:614-218-1012
Mailing Address - Fax:952-487-5935
Practice Address - Street 1:2808 F ST STE A
Practice Address - Street 2:
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93301-1833
Practice Address - Country:US
Practice Address - Phone:661-873-4216
Practice Address - Fax:661-829-0600
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-29
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAC53592207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular DiseaseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6474639Medicaid
CA6474639Medicaid
G43493Medicare UPIN