Provider Demographics
NPI:1538161443
Name:MALLAM, MOHAN (MD)
Entity type:Individual
Prefix:DR
First Name:MOHAN
Middle Name:
Last Name:MALLAM
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 1:303 E BUENA VISTA ST
Mailing Address - Street 2:
Mailing Address - City:BARSTOW
Mailing Address - State:CA
Mailing Address - Zip Code:92311-2803
Mailing Address - Country:US
Mailing Address - Phone:760-256-4601
Mailing Address - Fax:760-256-0310
Practice Address - Street 1:303 E BUENA VISTA ST
Practice Address - Street 2:
Practice Address - City:BARSTOW
Practice Address - State:CA
Practice Address - Zip Code:92311-2803
Practice Address - Country:US
Practice Address - Phone:760-256-4601
Practice Address - Fax:760-256-0310
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-10
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA42919207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A429190Medicaid
CALAB73093FMedicaid
A29647Medicare UPIN
00A429190Medicare ID - Type Unspecified