Provider Demographics
NPI:1275687998
Name:WITT, MALLORY (MD)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:WITT
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 1:1000 W CARSON ST
Mailing Address - Street 2:BOX 480
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90502-2004
Mailing Address - Country:US
Mailing Address - Phone:310-222-2365
Mailing Address - Fax:
Practice Address - Street 1:1000 W CARSON ST
Practice Address - Street 2:BOX 480
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90502-2004
Practice Address - Country:US
Practice Address - Phone:310-222-2365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-22
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG59860207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G598600Medicaid
CA00G598600Medicaid
CAF12105Medicare UPIN
CAWG59860EMedicare ID - Type UnspecifiedPPIN
CAWG59860GMedicare ID - Type UnspecifiedPPIN