Provider Demographics
NPI:1972513091
Name:MALL, MICHAEL SCOTT (MD)
Entity type:Individual
Prefix:MR
First Name:MICHAEL
Middle Name:SCOTT
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 1:7455 W WASHINGTON AVE
Mailing Address - Street 2:#400
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-4337
Mailing Address - Country:US
Mailing Address - Phone:702-733-7966
Mailing Address - Fax:702-341-0504
Practice Address - Street 1:7455 W WASHINGTON AVE
Practice Address - Street 2:#400
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-4337
Practice Address - Country:US
Practice Address - Phone:702-733-7966
Practice Address - Fax:702-341-0504
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2022-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVNV6074207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV003102017Medicaid
NV002019017Medicaid
E81407Medicare UPIN
NV002019017Medicaid