Provider Demographics
NPI:1053465062
Name:DOMINIQUE MALL,MD,INC
Entity Type:Organization
Organization Name:DOMINIQUE MALL,MD,INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DOMINIQUE
Authorized Official - Middle Name:LUCIENNE
Authorized Official - Last Name:MALL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-902-8947
Mailing Address - Street 1:13911 OLD HARBOR LN
Mailing Address - Street 2:#306
Mailing Address - City:MARINA DEL REY
Mailing Address - State:CA
Mailing Address - Zip Code:90292-7395
Mailing Address - Country:US
Mailing Address - Phone:310-577-9547
Mailing Address - Fax:310-577-9547
Practice Address - Street 1:13911 OLD HARBOR LN
Practice Address - Street 2:#306
Practice Address - City:MARINA DEL REY
Practice Address - State:CA
Practice Address - Zip Code:90292-7395
Practice Address - Country:US
Practice Address - Phone:310-577-9547
Practice Address - Fax:310-577-9547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-23
Last Update Date:2011-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ145953Medicare PIN
AZZ145955Medicare PIN