Provider Demographics
NPI:1619941804
Name:MALISETTI, RAJINI KATIPAMULA (MBBS)
Entity Type:Individual
Prefix:
First Name:RAJINI
Middle Name:KATIPAMULA
Last Name:MALISETTI
Suffix:
Gender:F
Credentials:MBBS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11850 BLACKFOOT NW
Mailing Address - Street 2:SUITE 100
Mailing Address - City:COON RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:55433-2569
Mailing Address - Country:US
Mailing Address - Phone:763-721-2100
Mailing Address - Fax:763-721-2190
Practice Address - Street 1:11850 BLACKFOOT NW
Practice Address - Street 2:SUITE 100
Practice Address - City:COON RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:55433-2569
Practice Address - Country:US
Practice Address - Phone:763-721-2100
Practice Address - Fax:763-721-2190
Is Sole Proprietor?:No
Enumeration Date:2006-02-14
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN47014207RH0003X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RH0003XAllopathic & Osteopathic PhysiciansInternal MedicineHematology & Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN115113400Medicaid
MNP00246771Medicare ID - Type UnspecifiedRAILROAD
MN830000427Medicare ID - Type Unspecified
MN115113400Medicaid