Provider Demographics
NPI:1376596015
Name:MALLAH, RADWAN (MD)
Entity Type:Individual
Prefix:
First Name:RADWAN
Middle Name:
Last Name:MALLAH
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:PO BOX 11047
Mailing Address - Street 2:
Mailing Address - City:DAYTONA BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32120-1047
Mailing Address - Country:US
Mailing Address - Phone:386-274-7800
Mailing Address - Fax:386-274-7801
Practice Address - Street 1:600 S 3RD ST
Practice Address - Street 2:
Practice Address - City:GADSDEN
Practice Address - State:AL
Practice Address - Zip Code:35901-5304
Practice Address - Country:US
Practice Address - Phone:256-543-5200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2019-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL18098207P00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL18098OtherWORKER'S COMP
AL51555451OtherBLUE SHIELD
AL051555451Medicaid
AL009911272Medicaid
AL51542980OtherBC BS