Provider Demographics
NPI:1144200262
Name:MALLAMPATI, KOMALA DEVI (MD)
Entity type:Individual
Prefix:
First Name:KOMALA
Middle Name:DEVI
Last Name:MALLAMPATI
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 1:514 JOYCE ST
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07050-1411
Mailing Address - Country:US
Mailing Address - Phone:973-672-2214
Mailing Address - Fax:973-672-1320
Practice Address - Street 1:514 JOYCE ST
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:NJ
Practice Address - Zip Code:07050-1411
Practice Address - Country:US
Practice Address - Phone:973-672-2214
Practice Address - Fax:973-672-1320
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA41876208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6413901Medicaid
545419Medicare ID - Type Unspecified
NJ6413901Medicaid