Provider Demographics
NPI:1568099166
Name:MALLADI, CHAITANYA LAKSHMIDHAR (MD)
Entity Type:Individual
Prefix:
First Name:CHAITANYA
Middle Name:LAKSHMIDHAR
Last Name:MALLADI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:CHATT
Other - Middle Name:
Other - Last Name:MALLADI
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:9500 GILMAN DRIVE, MAIL CODE 7411
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92037-7411
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9434 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:LA JOLLA
Practice Address - State:CA
Practice Address - Zip Code:92037-1337
Practice Address - Country:US
Practice Address - Phone:858-657-8530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-24
Last Update Date:2023-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX390200000X
CAA186034207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program