Provider Demographics
NPI:1619997525
Name:MALET'A, VIVIANA (MD)
Entity Type:Individual
Prefix:DR
First Name:VIVIANA
Middle Name:
Last Name:MALET'A
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:701 E 28TH ST
Mailing Address - Street 2:STE 200
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90806-2784
Mailing Address - Country:US
Mailing Address - Phone:562-264-3121
Mailing Address - Fax:562-216-6196
Practice Address - Street 1:1930 S BROAD ST
Practice Address - Street 2:UNIT 5
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19145-2328
Practice Address - Country:US
Practice Address - Phone:215-467-5870
Practice Address - Fax:215-467-5873
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2017-05-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD-062006-L208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA001660249Medicaid
PA001660249Medicaid
PAG56764Medicare UPIN