Provider Demographics
NPI:1427099159
Name:VALLALA, ANUPAMA (MD)
Entity type:Individual
Prefix:
First Name:ANUPAMA
Middle Name:
Last Name:VALLALA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2 TERMINAL DR
Mailing Address - Street 2:SUITE 8
Mailing Address - City:EAST ALTON
Mailing Address - State:IL
Mailing Address - Zip Code:62024-2201
Mailing Address - Country:US
Mailing Address - Phone:618-259-1419
Mailing Address - Fax:618-259-1502
Practice Address - Street 1:2 TERMINAL DR
Practice Address - Street 2:SUITE 8
Practice Address - City:EAST ALTON
Practice Address - State:IL
Practice Address - Zip Code:62024-2201
Practice Address - Country:US
Practice Address - Phone:618-259-1419
Practice Address - Fax:618-259-1502
Is Sole Proprietor?:No
Enumeration Date:2006-06-10
Last Update Date:2014-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036112205208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics