Provider Demographics
NPI:1902814015
Name:MALLADI, VIKRAM R (MD)
Entity Type:Individual
Prefix:
First Name:VIKRAM
Middle Name:R
Last Name:MALLADI
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 1:200 TAMAL PLAZA
Mailing Address - Street 2:SUITE 200
Mailing Address - City:CORTE MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:94925
Mailing Address - Country:US
Mailing Address - Phone:415-925-6900
Mailing Address - Fax:415-925-6919
Practice Address - Street 1:1350 S ELISEO DR
Practice Address - Street 2:
Practice Address - City:GREENBRAE
Practice Address - State:CA
Practice Address - Zip Code:94904-2011
Practice Address - Country:US
Practice Address - Phone:415-925-6900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2021-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA102626207RG0100X
TXL7623207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX612791Medicare PIN