Provider Demographics
NPI:1649380395
Name:TELLA, MALLIK N (MD)
Entity Type:Individual
Prefix:
First Name:MALLIK
Middle Name:N
Last Name:TELLA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10000 SE MAIN ST
Mailing Address - Street 2:SUITE 224
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97216-2470
Mailing Address - Country:US
Mailing Address - Phone:503-261-6961
Mailing Address - Fax:
Practice Address - Street 1:10000 SE MAIN ST
Practice Address - Street 2:SUITE 224
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2470
Practice Address - Country:US
Practice Address - Phone:503-261-6961
Practice Address - Fax:503-261-6959
Is Sole Proprietor?:No
Enumeration Date:2006-08-30
Last Update Date:2024-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD155385207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR500637769Medicaid
OR500637769Medicaid