Provider Demographics
NPI:1083714919
Name:MALL, GAGAN DEEP (MD)
Entity Type:Individual
Prefix:DR
First Name:GAGAN
Middle Name:DEEP
Last Name:MALL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:GAGAN
Other - Middle Name:DEEP
Other - Last Name:RAM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:596 EDENDERRY DR
Mailing Address - Street 2:
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95688-8560
Mailing Address - Country:US
Mailing Address - Phone:707-392-5086
Mailing Address - Fax:707-392-5086
Practice Address - Street 1:2100 NAPA VALLEJO HWY
Practice Address - Street 2:
Practice Address - City:NAPA
Practice Address - State:CA
Practice Address - Zip Code:94558-6234
Practice Address - Country:US
Practice Address - Phone:707-253-5434
Practice Address - Fax:707-254-2423
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2014-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK223702084P0800X, 2084P0805X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200091340AMedicaid
OK1122370Medicaid
OK200091340AMedicaid