Provider Demographics
NPI:1487622304
Name:MALLELA, RAJESH (MD)
Entity type:Individual
Prefix:
First Name:RAJESH
Middle Name:
Last Name:MALLELA
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 1:6626 E 75TH ST
Mailing Address - Street 2:SUITE 500
Mailing Address - City:INDIANA
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2890
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:208 CORWIN LN
Practice Address - Street 2:
Practice Address - City:KOKOMO
Practice Address - State:IN
Practice Address - Zip Code:46902-6612
Practice Address - Country:US
Practice Address - Phone:765-864-8700
Practice Address - Fax:765-864-8715
Is Sole Proprietor?:No
Enumeration Date:2006-03-08
Last Update Date:2020-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01055567A207RI0011X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Yes207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200388170Medicaid
INP01824494OtherRR MEDICARE
IN200388170AMedicaid
256480EMedicare PIN
IN200388170AMedicaid
INH72343Medicare UPIN
IN266180811Medicare PIN
IN247230003Medicare PIN
INP01824494OtherRR MEDICARE