Provider Demographics
NPI:1295289650
Name:SUNIL MALHOTRA MD LLC
Entity type:Organization
Organization Name:SUNIL MALHOTRA MD LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SUNIL
Authorized Official - Middle Name:
Authorized Official - Last Name:MALHOTRA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:662-536-3331
Mailing Address - Street 1:470 GOODMAN RD E
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-9557
Mailing Address - Country:US
Mailing Address - Phone:662-536-3331
Mailing Address - Fax:662-536-3329
Practice Address - Street 1:470 GOODMAN RD E
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-9557
Practice Address - Country:US
Practice Address - Phone:662-536-3331
Practice Address - Fax:662-536-3329
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GOOMAN MEDICAL CLINIC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-08-15
Last Update Date:2017-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3336C0003XSuppliersPharmacyCommunity/Retail Pharmacy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS02909778Medicaid
MS02909778Medicaid