Provider Demographics
NPI:1992885396
Name:MALLAMPALLI, ANTARA (MD)
Entity type:Individual
Prefix:
First Name:ANTARA
Middle Name:
Last Name:MALLAMPALLI
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 1:6567 E CARONDELET STE 215
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85710
Mailing Address - Country:US
Mailing Address - Phone:520-885-1402
Mailing Address - Fax:520-722-5887
Practice Address - Street 1:6567 E CARONDELET STE 215
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85710
Practice Address - Country:US
Practice Address - Phone:520-885-1402
Practice Address - Fax:520-722-5887
Is Sole Proprietor?:No
Enumeration Date:2006-10-17
Last Update Date:2014-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ42829207RC0200X, 207RP1001X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX158246201Medicaid
TX158246202Medicaid
TX8A9846Medicare PIN
TXP00385949Medicare PIN
1992885396Medicare PIN
G78738Medicare UPIN
TX158246202Medicaid
TXP00022169Medicare PIN