Provider Demographics
NPI:1568667863
Name:RASAMALLU, KISHORE REDDY (MD)
Entity type:Individual
Prefix:
First Name:KISHORE
Middle Name:REDDY
Last Name:RASAMALLU
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:VIJAYA KISHORE
Other - Middle Name:
Other - Last Name:RASAMALLU
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:12895 KEYSTONE CT
Mailing Address - Street 2:
Mailing Address - City:ALPHARETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30009-1526
Mailing Address - Country:US
Mailing Address - Phone:210-379-8553
Mailing Address - Fax:910-900-1239
Practice Address - Street 1:12895 KEYSTONE CT
Practice Address - Street 2:
Practice Address - City:ALPHARETTA
Practice Address - State:GA
Practice Address - Zip Code:30009-1526
Practice Address - Country:US
Practice Address - Phone:210-379-8553
Practice Address - Fax:910-900-1239
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2024-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD432046208M00000X, 207R00000X
GA077148207R00000X
TXM9598207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2864090000OtherPERSONAL CHOICE
PA30046047OtherKEYSTONE MERCY
PA1020162720001Medicaid
PA1988201OtherHIGHMARK BLUE SHIELD
PA39170OtherHEALTH PARTNERS
PA2864090000OtherKEYSTONE IBC
PA1747437OtherAETNA
PA30046047OtherKEYSTONE MERCY
PA1020162720001Medicaid