Provider Demographics
NPI:1730603630
Name:MALLADI, SAMYUKTA (DO)
Entity type:Individual
Prefix:
First Name:SAMYUKTA
Middle Name:
Last Name:MALLADI
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:221 TRUMBULL ST APT 3001
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06103-1528
Mailing Address - Country:US
Mailing Address - Phone:847-208-5800
Mailing Address - Fax:
Practice Address - Street 1:759 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MA
Practice Address - Zip Code:01199-1500
Practice Address - Country:US
Practice Address - Phone:413-794-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-01
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA288350207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology