Provider Demographics
NPI:1265823793
Name:MALLIPUDI, ANDRES DIEZCANSECO (MD)
Entity type:Individual
Prefix:
First Name:ANDRES
Middle Name:DIEZCANSECO
Last Name:MALLIPUDI
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 1:202 N DIVISION ST
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:WA
Mailing Address - Zip Code:98001-4939
Mailing Address - Country:US
Mailing Address - Phone:800-225-0953
Mailing Address - Fax:
Practice Address - Street 1:202 N DIVISION ST
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:WA
Practice Address - Zip Code:98001-4939
Practice Address - Country:US
Practice Address - Phone:800-225-0953
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-05
Last Update Date:2024-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA292098207P00000X
WAMD61518915207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH3134859Medicaid
MA110187275AMedicaid