Provider Demographics
NPI:1629065511
Name:MALLADI, SUHASINI (MD)
Entity Type:Individual
Prefix:
First Name:SUHASINI
Middle Name:
Last Name:MALLADI
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:319 GASLIGHT BLVD
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75904-3124
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:319 GASLIGHT BLVD
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75904-3124
Practice Address - Country:US
Practice Address - Phone:936-634-3713
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-05
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG1948208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXE80990Medicare UPIN