Provider Demographics
NPI:1174651848
Name:NELLORE, MALLEESWARI (MD)
Entity Type:Individual
Prefix:DR
First Name:MALLEESWARI
Middle Name:
Last Name:NELLORE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MALLEESWARI
Other - Middle Name:
Other - Last Name:GANGIREDDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:11608 BROCKMAN LN
Mailing Address - Street 2:
Mailing Address - City:GREAT FALLS
Mailing Address - State:VA
Mailing Address - Zip Code:22066-1138
Mailing Address - Country:US
Mailing Address - Phone:888-464-2466
Mailing Address - Fax:
Practice Address - Street 1:11608 BROCKMAN LN
Practice Address - Street 2:
Practice Address - City:GREAT FALLS
Practice Address - State:VA
Practice Address - Zip Code:22066-1138
Practice Address - Country:US
Practice Address - Phone:888-464-2466
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012688242084N0400X
KY44166390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program