Provider Demographics
NPI:1124252705
Name:MARY MALLAVARAPU MD
Entity type:Organization
Organization Name:MARY MALLAVARAPU MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:ANITA
Authorized Official - Middle Name:
Authorized Official - Last Name:SOARES
Authorized Official - Suffix:
Authorized Official - Credentials:MBA
Authorized Official - Phone:845-634-0068
Mailing Address - Street 1:971 ROUTE 45
Mailing Address - Street 2:SUITE 112
Mailing Address - City:POMONA
Mailing Address - State:NY
Mailing Address - Zip Code:10970-3500
Mailing Address - Country:US
Mailing Address - Phone:845-354-8054
Mailing Address - Fax:845-354-1807
Practice Address - Street 1:100 PHILLIPS HILL RD
Practice Address - Street 2:
Practice Address - City:NEW CITY
Practice Address - State:NY
Practice Address - Zip Code:10956-4134
Practice Address - Country:US
Practice Address - Phone:845-634-0068
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MARY MALLAVARAPU MD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-05-11
Last Update Date:2009-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY121643208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00515435Medicaid
NY00515435Medicaid