Provider Demographics
NPI:1619139094
Name:MALLIPATTU, SANDEEP
Entity Type:Individual
Prefix:
First Name:SANDEEP
Middle Name:
Last Name:MALLIPATTU
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1554
Mailing Address - Street 2:STONY BROOK
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-0988
Mailing Address - Country:US
Mailing Address - Phone:631-444-0650
Mailing Address - Fax:631-638-4170
Practice Address - Street 1:26 RESEARCH WAY
Practice Address - Street 2:STONY BROOK INTERNISTS, UFPC
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733
Practice Address - Country:US
Practice Address - Phone:631-444-0580
Practice Address - Fax:631-444-0562
Is Sole Proprietor?:No
Enumeration Date:2008-06-27
Last Update Date:2013-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY250660207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology