Provider Demographics
NPI:1629016050
Name:MALL, JAY CHANAN (MD)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:CHANAN
Last Name:MALL
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 6102
Mailing Address - Street 2:
Mailing Address - City:NOVATO
Mailing Address - State:CA
Mailing Address - Zip Code:94948-6102
Mailing Address - Country:US
Mailing Address - Phone:415-884-3418
Mailing Address - Fax:415-883-8082
Practice Address - Street 1:3700 CALIFORNIA ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94118-1618
Practice Address - Country:US
Practice Address - Phone:415-750-6025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-04
Last Update Date:2008-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG225172085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G225170Medicaid
CA300130339OtherRAILROAD MEDICARE
CA00G225174Medicare PIN
CA00G225172Medicare PIN
CAA41611Medicare UPIN
CA00G225173Medicare PIN
CA00G225170Medicaid