Provider Demographics
NPI:1265405997
Name:PIDURU, MALLIK A (MD)
Entity type:Individual
Prefix:DR
First Name:MALLIK
Middle Name:A
Last Name:PIDURU
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 1:15215 CORTEZ BLVD
Mailing Address - Street 2:
Mailing Address - City:BROOKSVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:34613-6072
Mailing Address - Country:US
Mailing Address - Phone:352-799-0046
Mailing Address - Fax:727-861-1881
Practice Address - Street 1:11373 CORTEZ BLVD
Practice Address - Street 2:SUITE 201
Practice Address - City:BROOKSVILLE
Practice Address - State:FL
Practice Address - Zip Code:34613-5414
Practice Address - Country:US
Practice Address - Phone:352-596-7860
Practice Address - Fax:352-597-3657
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME0044053208600000X, 2086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLP00984624OtherRR MCR
FL036160700Medicaid
FL26064OtherBCBS
FLP00867800OtherRR MCR ATTACHED TO GRP# CH7269
FL165252OtherWELLCARE
FLP00867800OtherRR MCR ATTACHED TO GRP# CH7269
FLP00984624OtherRR MCR
FLD53444Medicare UPIN
FL036160700Medicaid