Provider Demographics
NPI:1184682411
Name:MILAM, MALLORY STANTON JR (MD)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:STANTON
Last Name:MILAM
Suffix:JR
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:PO BOX 5486
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CA
Mailing Address - Zip Code:92863-5486
Mailing Address - Country:US
Mailing Address - Phone:818-550-0900
Mailing Address - Fax:818-550-0900
Practice Address - Street 1:16055 VENTURA BLVD STE 120
Practice Address - Street 2:
Practice Address - City:ENCINO
Practice Address - State:CA
Practice Address - Zip Code:91436-2635
Practice Address - Country:US
Practice Address - Phone:424-499-7124
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-03
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA78479207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
H39108Medicare UPIN
WA78479CMedicare ID - Type Unspecified