Provider Demographics
NPI:1861488215
Name:DAMALLIE, KUSHNA K (MD)
Entity type:Individual
Prefix:DR
First Name:KUSHNA
Middle Name:K
Last Name:DAMALLIE
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 1:2000 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:CLARKSDALE
Mailing Address - State:MS
Mailing Address - Zip Code:38614-6100
Mailing Address - Country:US
Mailing Address - Phone:662-627-7361
Mailing Address - Fax:662-627-1158
Practice Address - Street 1:2000 N STATE ST
Practice Address - Street 2:
Practice Address - City:CLARKSDALE
Practice Address - State:MS
Practice Address - Zip Code:38614-6100
Practice Address - Country:US
Practice Address - Phone:662-627-7361
Practice Address - Fax:662-627-1158
Is Sole Proprietor?:No
Enumeration Date:2005-09-21
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN35758207V00000X
MS18061174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09035591Medicaid
MS150159001OtherARK MEDICAID
MS82604OtherARK BCBS
MS09035591Medicaid
MSH61614Medicare UPIN