Provider Demographics
NPI:1194043554
Name:MALLELA, RATHNA SREE (MD, MPH)
Entity Type:Individual
Prefix:
First Name:RATHNA
Middle Name:SREE
Last Name:MALLELA
Suffix:
Gender:F
Credentials:MD, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2600 HUMES RD STE 100
Mailing Address - Street 2:
Mailing Address - City:JANESVILLE
Mailing Address - State:WI
Mailing Address - Zip Code:53545-0491
Mailing Address - Country:US
Mailing Address - Phone:608-741-2117
Mailing Address - Fax:608-758-5761
Practice Address - Street 1:2600 HUMES RD STE 100
Practice Address - Street 2:
Practice Address - City:JANESVILLE
Practice Address - State:WI
Practice Address - Zip Code:53545-0491
Practice Address - Country:US
Practice Address - Phone:608-741-2117
Practice Address - Fax:608-758-5761
Is Sole Proprietor?:No
Enumeration Date:2010-05-11
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WI64316-202084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
WIK400258434-00084908OtherWI MEDICARE
WI1194043554OtherBCBSWI
WI1194043554OtherDEANHEALTH PLAN
WI1194043554Medicaid
WIK400258432-000054176OtherWI MEDICARE
WIMALLERATOtherMERCYCARE INSURANCE