Provider Demographics
NPI:1376786947
Name:MALLIDI, JAYA REDDY (MD)
Entity type:Individual
Prefix:
First Name:JAYA
Middle Name:REDDY
Last Name:MALLIDI
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 1:500 DOYLE PARK DR STE G05
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95405-4555
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:500 DOYLE PARK DR STE G05
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95405-4555
Practice Address - Country:US
Practice Address - Phone:707-576-7100
Practice Address - Fax:707-576-8482
Is Sole Proprietor?:No
Enumeration Date:2009-04-13
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA252857207R00000X, 208M00000X
CAA134248207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist