Provider Demographics
NPI:1265465488
Name:EL-MALLAWANY, JUNG JIN (MD)
Entity Type:Individual
Prefix:
First Name:JUNG
Middle Name:JIN
Last Name:EL-MALLAWANY
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 1:12300 MCCRACKEN RD
Mailing Address - Street 2:
Mailing Address - City:GARFIELD HEIGHTS
Mailing Address - State:OH
Mailing Address - Zip Code:44125-2914
Mailing Address - Country:US
Mailing Address - Phone:216-587-8334
Mailing Address - Fax:216-587-8646
Practice Address - Street 1:12300 MCCRACKEN RD
Practice Address - Street 2:
Practice Address - City:GARFIELD HEIGHTS
Practice Address - State:OH
Practice Address - Zip Code:44125-2914
Practice Address - Country:US
Practice Address - Phone:216-587-8334
Practice Address - Fax:216-587-8646
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2011-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.04.17112084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHT41711OtherSUMMACARE HEALTH PLAN
OH000000216102OtherANTHEM PIN NUMBER
OH741167OtherBUCKEYE HEALTH PLAN
OH000000216102OtherUNICARE
OH4007204OtherAETNA
OH0600040Medicaid
OH350983OtherWELLCARE OF OHIO
OH0497789Medicare PIN
OH350983OtherWELLCARE OF OHIO
OH0600040Medicaid
OH7234621Medicare PIN
OH7421001Medicare PIN