Provider Demographics
NPI:1801039441
Name:EM, MAKKALON (MD)
Entity type:Individual
Prefix:
First Name:MAKKALON
Middle Name:
Last Name:EM
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 1:99 N MAIN ST APT 607
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-5004
Mailing Address - Country:US
Mailing Address - Phone:310-294-0874
Mailing Address - Fax:
Practice Address - Street 1:99 N MAIN ST APT 607
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103-5004
Practice Address - Country:US
Practice Address - Phone:310-294-0874
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-04-13
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD455835208600000X
MEMD20797208600000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAMD455835OtherPA LICENSE