Provider Demographics
NPI:1164499554
Name:PATTA, MALLIKARJUN (MD)
Entity type:Individual
Prefix:DR
First Name:MALLIKARJUN
Middle Name:
Last Name:PATTA
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:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:12750 SAINT FRANCIS DR
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-0264
Practice Address - Country:US
Practice Address - Phone:219-852-1524
Practice Address - Fax:219-933-2288
Is Sole Proprietor?:No
Enumeration Date:2006-03-03
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01057540A2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200428170AMedicaid
IN200428170AMedicaid
G85461Medicare UPIN