Provider Demographics
NPI:1992907760
Name:MULAMALLA, KEERTHI (MD)
Entity type:Individual
Prefix:
First Name:KEERTHI
Middle Name:
Last Name:MULAMALLA
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 1:145 N MEDICAL PKWY
Mailing Address - Street 2:
Mailing Address - City:WOODSTOCK
Mailing Address - State:GA
Mailing Address - Zip Code:30189-7031
Mailing Address - Country:US
Mailing Address - Phone:770-592-3000
Mailing Address - Fax:770-592-3075
Practice Address - Street 1:145 N MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:WOODSTOCK
Practice Address - State:GA
Practice Address - Zip Code:30189-7031
Practice Address - Country:US
Practice Address - Phone:770-592-3000
Practice Address - Fax:770-592-3075
Is Sole Proprietor?:No
Enumeration Date:2007-06-04
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAR8013207Q00000X
GA69073207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA06601009OtherECFMG