Provider Demographics
NPI:1316989197
Name:TADAKAMALLA, MALATHI (MD)
Entity type:Individual
Prefix:DR
First Name:MALATHI
Middle Name:
Last Name:TADAKAMALLA
Suffix:
Gender:F
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:PO BOX 219209
Mailing Address - Street 2:
Mailing Address - City:KANSAS CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64121-9209
Mailing Address - Country:US
Mailing Address - Phone:913-226-7332
Mailing Address - Fax:913-674-5563
Practice Address - Street 1:600 NE MEADOWVIEW DR
Practice Address - Street 2:
Practice Address - City:LEES SUMMIT
Practice Address - State:MO
Practice Address - Zip Code:64064-1983
Practice Address - Country:US
Practice Address - Phone:913-226-7332
Practice Address - Fax:913-674-5563
Is Sole Proprietor?:No
Enumeration Date:2006-06-13
Last Update Date:2015-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2009003023207QG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QG0300XAllopathic & Osteopathic PhysiciansFamily MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOMA3153001,OtherMEDICARE PTAN
MOMA1039009Medicare PIN
MOMA1038009Medicare PIN
KSKA1093008Medicare PIN