Provider Demographics
NPI:1144596495
Name:MALLELA, KALYANCHAKRAVARTHI (MD)
Entity Type:Individual
Prefix:DR
First Name:KALYANCHAKRAVARTHI
Middle Name:
Last Name:MALLELA
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 1:3231 MCMULLEN BOOTH RD FL 1
Mailing Address - Street 2:
Mailing Address - City:SAFETY HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34695-6607
Mailing Address - Country:US
Mailing Address - Phone:727-725-6905
Mailing Address - Fax:727-266-4931
Practice Address - Street 1:3231 MCMULLEN BOOTH RD FL 1
Practice Address - Street 2:
Practice Address - City:SAFETY HARBOR
Practice Address - State:FL
Practice Address - Zip Code:34695-6607
Practice Address - Country:US
Practice Address - Phone:727-725-6905
Practice Address - Fax:727-266-4931
Is Sole Proprietor?:No
Enumeration Date:2012-03-30
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT200775207Q00000X
FLME124997207Q00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL016559800Medicaid
FLIM270WMedicare PIN
FL016559800Medicaid