Provider Demographics
NPI:1588648588
Name:MALLYA, SARITA (MD)
Entity Type:Individual
Prefix:
First Name:SARITA
Middle Name:
Last Name:MALLYA
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 1:500 VINE ST
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06112-1639
Mailing Address - Country:US
Mailing Address - Phone:860-297-0800
Mailing Address - Fax:
Practice Address - Street 1:51 COVENTRY ST
Practice Address - Street 2:
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06112-1525
Practice Address - Country:US
Practice Address - Phone:860-297-0800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT420832084P0800X
CAC542592084P0800X
CT0420832084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT260004419Medicare ID - Type Unspecified
CTI17615Medicare UPIN