Provider Demographics
NPI:1851498729
Name:MALLELA, SUDHAKAR V (MD)
Entity Type:Individual
Prefix:
First Name:SUDHAKAR
Middle Name:V
Last Name:MALLELA
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 1:6885 BROCKTON AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-3811
Mailing Address - Country:US
Mailing Address - Phone:951-462-1306
Mailing Address - Fax:951-784-8934
Practice Address - Street 1:6885 BROCKTON AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506
Practice Address - Country:US
Practice Address - Phone:951-468-1306
Practice Address - Fax:951-784-8934
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2023-03-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV9640207R00000X, 207RI0200X
CAC131483207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002018743Medicaid
NV002018743Medicaid