Provider Demographics
NPI:1982936126
Name:SUNIL MALHOTRA
Entity Type:Organization
Organization Name:SUNIL MALHOTRA
Other - Org Name:GOODMAN MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER / PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SUNIL
Authorized Official - Middle Name:
Authorized Official - Last Name:MALHOTRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-536-3330
Mailing Address - Street 1:470 GOODMAN RD E
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-9557
Mailing Address - Country:US
Mailing Address - Phone:662-536-3330
Mailing Address - Fax:662-536-3329
Practice Address - Street 1:470 GOODMAN RD E
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-9557
Practice Address - Country:US
Practice Address - Phone:662-536-3330
Practice Address - Fax:662-536-3329
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-12
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS14652207Q00000X
MS14796207R00000X
MS80187213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00117366Medicaid
MS00117366Medicaid