Individual
DR. MALLIK A PIDURU
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
M.D.
Contact information
Practice address
11373 CORTEZ BLVD, SUITE 201, BROOKSVILLE, FL 34613-5414
(352) 596-7860
(352) 597-3657
Mailing address
15215 CORTEZ BLVD, BROOKSVILLE, FL 34613-6072
(352) 799-0046
(727) 861-1881
Taxonomy
Speciality
Code
Description
License number
State
208600000X
Surgery Physician
Primary
ME0044053
FL
2086S0129X
Vascular Surgery Physician
ME0044053
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
036160700
—
FL
01
—
165252
WELLCARE
FL
01
—
26064
BCBS
FL
01
—
P00867800
RR MCR ATTACHED TO GRP# CH7269
FL
01
—
P00984624
RR MCR
FL
Enumeration date
02/13/2006
Last updated
01/24/2012
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