Provider Demographics
NPI:1265410831
Name:MALLI, DIPAKKUMAR PURUSHOTTAM (MD)
Entity type:Individual
Prefix:
First Name:DIPAKKUMAR
Middle Name:PURUSHOTTAM
Last Name:MALLI
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 1:1416 SPRUCE AVE
Mailing Address - Street 2:
Mailing Address - City:VOORHEES
Mailing Address - State:NJ
Mailing Address - Zip Code:08043-3649
Mailing Address - Country:US
Mailing Address - Phone:609-471-1000
Mailing Address - Fax:856-427-9199
Practice Address - Street 1:140 E EVESHAM RD
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08003-3949
Practice Address - Country:US
Practice Address - Phone:856-427-4477
Practice Address - Fax:856-427-9199
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07352400207RP1001X, 207RC0200X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Not Answered207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
Not Answered207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJH99396Medicare UPIN