Provider Demographics
NPI:1770049561
Name:MALLELA, DHIRAJ
Entity type:Individual
Prefix:
First Name:DHIRAJ
Middle Name:
Last Name:MALLELA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:537 S 3RD ST APT 613
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1869
Mailing Address - Country:US
Mailing Address - Phone:603-930-8999
Mailing Address - Fax:
Practice Address - Street 1:537 S 3RD ST APT 613
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1869
Practice Address - Country:US
Practice Address - Phone:603-930-8999
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-16
Last Update Date:2019-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program