Provider Demographics
NPI:1245421403
Name:MALLAH, JAMIE A (MD)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:A
Last Name:MALLAH
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4902 EISENHOWER BLVD
Mailing Address - Street 2:SUITE 300
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33634-6344
Mailing Address - Country:US
Mailing Address - Phone:813-636-2000
Mailing Address - Fax:813-286-8835
Practice Address - Street 1:4683 VAN DYKE RD
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33558-4880
Practice Address - Country:US
Practice Address - Phone:813-968-7171
Practice Address - Fax:813-968-7282
Is Sole Proprietor?:No
Enumeration Date:2007-08-05
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME98703208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL279016500Medicaid
FL17438Medicare PIN