Provider Demographics
NPI:1588619134
Name:MALA THENAPPAN, MD
Entity Type:Organization
Organization Name:MALA THENAPPAN, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MALA
Authorized Official - Middle Name:
Authorized Official - Last Name:THENAPPAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:414-875-9950
Mailing Address - Street 1:3070 N 51ST ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53210-1645
Mailing Address - Country:US
Mailing Address - Phone:414-875-9950
Mailing Address - Fax:414-447-2575
Practice Address - Street 1:3070 N 51ST ST
Practice Address - Street 2:SUITE 100
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53210-1645
Practice Address - Country:US
Practice Address - Phone:414-875-9950
Practice Address - Fax:414-447-2575
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32430500Medicaid