Provider Demographics
NPI:1568667863
Name:RASAMALLU, KISHORE REDDY (MD)
Entity Type:Individual
Prefix:
First Name:KISHORE
Middle Name:REDDY
Last Name:RASAMALLU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:VIJAYA KISHORE
Other - Middle Name:
Other - Last Name:RASAMALLU
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:704 BREEDLOVE DR
Mailing Address - Street 2:STE A
Mailing Address - City:MONROE
Mailing Address - State:GA
Mailing Address - Zip Code:30655-2054
Mailing Address - Country:US
Mailing Address - Phone:512-730-3060
Mailing Address - Fax:888-730-1925
Practice Address - Street 1:400 ROSALIND REDFERN GROVER PKWY
Practice Address - Street 2:
Practice Address - City:MIDLAND
Practice Address - State:TX
Practice Address - Zip Code:79701-5846
Practice Address - Country:US
Practice Address - Phone:512-730-3060
Practice Address - Fax:888-730-1925
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2019-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD432046207R00000X, 208M00000X
TXM9598208M00000X, 207R00000X
GA077148207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1020162720001Medicaid
PA2864090000OtherKEYSTONE IBC
PA2864090000OtherPERSONAL CHOICE
PA39170OtherHEALTH PARTNERS
PA1988201OtherHIGHMARK BLUE SHIELD
PA1747437OtherAETNA
PA30046047OtherKEYSTONE MERCY
PA30046047OtherKEYSTONE MERCY
PA1020162720001Medicaid