Provider Demographics
NPI:1336279801
Name:SEETHARAM, MALAVALLI (MD)
Entity Type:Individual
Prefix:DR
First Name:MALAVALLI
Middle Name:
Last Name:SEETHARAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:MALAVALLI
Other - Middle Name:
Other - Last Name:SEETHARAM
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:1524 MCHENRY AVE
Mailing Address - Street 2:SUITE 570
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-4500
Mailing Address - Country:US
Mailing Address - Phone:209-572-3880
Mailing Address - Fax:209-572-3349
Practice Address - Street 1:1524 MCHENRY AVE
Practice Address - Street 2:SUITE 570
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4500
Practice Address - Country:US
Practice Address - Phone:209-572-3880
Practice Address - Fax:209-572-3349
Is Sole Proprietor?:No
Enumeration Date:2007-03-06
Last Update Date:2013-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1991692084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
B08210Medicare UPIN