Provider Demographics
NPI:1790125615
Name:BAGEWADI ELLUR, MALLIKARJUNA (MD,)
Entity type:Individual
Prefix:DR
First Name:MALLIKARJUNA
Middle Name:
Last Name:BAGEWADI ELLUR
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 1:104 WELLS AVE
Mailing Address - Street 2:
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29646-3837
Mailing Address - Country:US
Mailing Address - Phone:864-725-4673
Mailing Address - Fax:864-725-7424
Practice Address - Street 1:1325 SPRING ST
Practice Address - Street 2:
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29646-3860
Practice Address - Country:US
Practice Address - Phone:864-725-4398
Practice Address - Fax:864-725-4399
Is Sole Proprietor?:No
Enumeration Date:2013-06-25
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC909532084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty