Provider Demographics
NPI:1982645297
Name:KAMISHETTI, MALLIKARJUN (MD)
Entity Type:Individual
Prefix:
First Name:MALLIKARJUN
Middle Name:
Last Name:KAMISHETTI
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:PO BOX 55
Mailing Address - Street 2:
Mailing Address - City:HOPKINSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42241-0055
Mailing Address - Country:US
Mailing Address - Phone:270-887-0100
Mailing Address - Fax:270-887-0342
Practice Address - Street 1:320 W 18TH ST
Practice Address - Street 2:
Practice Address - City:HOPKINSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42240-1965
Practice Address - Country:US
Practice Address - Phone:270-887-0100
Practice Address - Fax:270-887-0342
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2014-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY39952207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000559181OtherANTHEM BCBS
KY64129414Medicaid
KY000000559181OtherANTHEM BCBS
I62245Medicare UPIN