Provider Demographics
NPI:1861620007
Name:MOLAKATALLA, PHANI KISHORE (MD)
Entity type:Individual
Prefix:
First Name:PHANI
Middle Name:KISHORE
Last Name:MOLAKATALLA
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 1:250 GREEN ST
Mailing Address - Street 2:SUITE 209
Mailing Address - City:GARDNER
Mailing Address - State:MA
Mailing Address - Zip Code:01440-1396
Mailing Address - Country:US
Mailing Address - Phone:978-669-5522
Mailing Address - Fax:978-632-0516
Practice Address - Street 1:250 GREEN ST
Practice Address - Street 2:SUITE 209
Practice Address - City:GARDNER
Practice Address - State:MA
Practice Address - Zip Code:01440-1396
Practice Address - Country:US
Practice Address - Phone:978-669-5522
Practice Address - Fax:978-632-0516
Is Sole Proprietor?:Yes
Enumeration Date:2009-06-25
Last Update Date:2015-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD447302207R00000X
PAMT194411390200000X
MA261931207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program