Provider Demographics
NPI:1437437613
Name:MALLAM, DIVYA (MD)
Entity Type:Individual
Prefix:
First Name:DIVYA
Middle Name:
Last Name:MALLAM
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 1:11480 BROOKSHIRE AVE STE 204
Mailing Address - Street 2:
Mailing Address - City:DOWNEY
Mailing Address - State:CA
Mailing Address - Zip Code:90241-5023
Mailing Address - Country:US
Mailing Address - Phone:310-386-4524
Mailing Address - Fax:
Practice Address - Street 1:11480 BROOKSHIRE AVE STE 204
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90241-5023
Practice Address - Country:US
Practice Address - Phone:562-904-4445
Practice Address - Fax:562-904-4441
Is Sole Proprietor?:No
Enumeration Date:2011-07-22
Last Update Date:2021-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA123488207RG0100X, 207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
14584255OtherCAQH