Provider Demographics
NPI:1598949547
Name:MALLU, VENKATA C (MD)
Entity Type:Individual
Prefix:
First Name:VENKATA
Middle Name:C
Last Name:MALLU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:101 ROYAL CREST CIR
Mailing Address - Street 2:
Mailing Address - City:KATHLEEN
Mailing Address - State:GA
Mailing Address - Zip Code:31047-2144
Mailing Address - Country:US
Mailing Address - Phone:478-319-5962
Mailing Address - Fax:478-745-8932
Practice Address - Street 1:777 HEMLOCK ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-2102
Practice Address - Country:US
Practice Address - Phone:478-741-7241
Practice Address - Fax:478-745-8932
Is Sole Proprietor?:No
Enumeration Date:2007-12-27
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA062252208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA586433793Medicaid
GA586433793Medicaid