Provider Demographics
NPI:1215938360
Name:MALLADI, BHAGVAN R (MD)
Entity type:Individual
Prefix:
First Name:BHAGVAN
Middle Name:R
Last Name:MALLADI
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 1:319 GASLIGHT BLVD
Mailing Address - Street 2:
Mailing Address - City:LUFKIN
Mailing Address - State:TX
Mailing Address - Zip Code:75901
Mailing Address - Country:US
Mailing Address - Phone:936-634-3713
Mailing Address - Fax:936-634-8136
Practice Address - Street 1:319 GASLIGHT BLVD
Practice Address - Street 2:
Practice Address - City:LUFKIN
Practice Address - State:TX
Practice Address - Zip Code:75901
Practice Address - Country:US
Practice Address - Phone:936-634-3713
Practice Address - Fax:936-634-8136
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2012-12-12
Deactivation Date:2006-03-23
Deactivation Code:
Reactivation Date:2006-03-28
Provider Licenses
StateLicense IDTaxonomies
TXG2092207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8J3446OtherBLUE CROSS
TX035782401Medicaid
TX8J3446OtherBLUE CROSS
00RW40Medicare PIN