Provider Demographics
NPI:1629319157
Name:MALLA, PRASANNA (MD)
Entity Type:Individual
Prefix:
First Name:PRASANNA
Middle Name:
Last Name:MALLA
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 1:276 ENGLE ST
Mailing Address - Street 2:APT 9B
Mailing Address - City:ENGLEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07631-2441
Mailing Address - Country:US
Mailing Address - Phone:201-681-8476
Mailing Address - Fax:
Practice Address - Street 1:276 ENGLE ST
Practice Address - Street 2:APT 9B
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-2441
Practice Address - Country:US
Practice Address - Phone:201-681-8476
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-07
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program