Provider Demographics
NPI:1316525058
Name:MALL, PRESTON W (MD)
Entity type:Individual
Prefix:
First Name:PRESTON
Middle Name:W
Last Name:MALL
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 1:439 WOODGATE BLVD
Mailing Address - Street 2:
Mailing Address - City:BATON ROUGE
Mailing Address - State:LA
Mailing Address - Zip Code:70808-5423
Mailing Address - Country:US
Mailing Address - Phone:225-978-9733
Mailing Address - Fax:
Practice Address - Street 1:439 WOODGATE BLVD
Practice Address - Street 2:
Practice Address - City:BATON ROUGE
Practice Address - State:LA
Practice Address - Zip Code:70808-5423
Practice Address - Country:US
Practice Address - Phone:225-978-9733
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-01
Last Update Date:2021-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program