Provider Demographics
NPI:1205817525
Name:MALLA, YOGESH B (MD)
Entity Type:Individual
Prefix:
First Name:YOGESH
Middle Name:B
Last Name:MALLA
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 1:2831 LONE OAK RD
Mailing Address - Street 2:
Mailing Address - City:PADUCAH
Mailing Address - State:KY
Mailing Address - Zip Code:42003-8041
Mailing Address - Country:US
Mailing Address - Phone:270-554-8373
Mailing Address - Fax:270-554-8987
Practice Address - Street 1:2831 LONE OAK RD
Practice Address - Street 2:
Practice Address - City:PADUCAH
Practice Address - State:KY
Practice Address - Zip Code:42003-8041
Practice Address - Country:US
Practice Address - Phone:270-554-8373
Practice Address - Fax:270-554-8987
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2012-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY38503208VP0014X, 207L00000X
IL036112552208VP0014X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000338788OtherBC/BS
KY64080393Medicaid
ILK12438Medicare ID - Type UnspecifiedMEDICARE
H54855Medicare UPIN
KY64080393Medicaid
P00135236Medicare ID - Type UnspecifiedRAILROAD MEDICARE