Provider Demographics
NPI:1285656900
Name:MALL, ANIL D (MD)
Entity Type:Individual
Prefix:DR
First Name:ANIL
Middle Name:D
Last Name:MALL
Suffix:
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 1:1023 S MOUNT VERNON AVE STE A
Mailing Address - Street 2:
Mailing Address - City:COLTON
Mailing Address - State:CA
Mailing Address - Zip Code:92324-4202
Mailing Address - Country:US
Mailing Address - Phone:909-533-4443
Mailing Address - Fax:951-533-4483
Practice Address - Street 1:1023 S MOUNT VERNON AVE STE A
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-4202
Practice Address - Country:US
Practice Address - Phone:909-533-4443
Practice Address - Fax:909-533-4483
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2021-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA60590207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG67700Medicare UPIN