Provider Demographics
NPI:1962476127
Name:CHALLAPALLI, MALLISWARI (MD)
Entity Type:Individual
Prefix:
First Name:MALLISWARI
Middle Name:
Last Name:CHALLAPALLI
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 1:2160 S 1ST AVE
Mailing Address - Street 2:(MAGUIRE CENTER, RM. 3307)
Mailing Address - City:MAYWOOD
Mailing Address - State:IL
Mailing Address - Zip Code:60153-3328
Mailing Address - Country:US
Mailing Address - Phone:708-216-4403
Mailing Address - Fax:708-216-3375
Practice Address - Street 1:2160 S 1ST AVE
Practice Address - Street 2:(MAGUIRE CENTER, RM. 3307)
Practice Address - City:MAYWOOD
Practice Address - State:IL
Practice Address - Zip Code:60153-3328
Practice Address - Country:US
Practice Address - Phone:708-216-4403
Practice Address - Fax:708-216-3375
Is Sole Proprietor?:No
Enumeration Date:2006-02-15
Last Update Date:2009-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL360543662080P0208X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0208XAllopathic & Osteopathic PhysiciansPediatricsPediatric Infectious Diseases
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL36054366Medicaid
IL36054366Medicaid
IL388060Medicare ID - Type Unspecified