Provider Demographics
NPI:1275552952
Name:MALL, SHARAL (DO)
Entity Type:Individual
Prefix:
First Name:SHARAL
Middle Name:
Last Name:MALL
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3614 E SALINAS CIR
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45440-3965
Mailing Address - Country:US
Mailing Address - Phone:937-848-6408
Mailing Address - Fax:
Practice Address - Street 1:540 LINCOLN PARK BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45429-6401
Practice Address - Country:US
Practice Address - Phone:937-299-0900
Practice Address - Fax:937-297-6303
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH340069342085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHG93471Medicare UPIN