Provider Demographics
NPI:1659527331
Name:MALL, SANJEEV KUMAR (MD)
Entity Type:Individual
Prefix:DR
First Name:SANJEEV
Middle Name:KUMAR
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 1:13576 MERCEDES LN
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75035-0649
Mailing Address - Country:US
Mailing Address - Phone:714-598-7578
Mailing Address - Fax:714-740-5876
Practice Address - Street 1:13576 MERCEDES LN
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75035-0649
Practice Address - Country:US
Practice Address - Phone:714-598-7578
Practice Address - Fax:714-740-5876
Is Sole Proprietor?:No
Enumeration Date:2008-08-13
Last Update Date:2021-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA114766207Q00000X
TXP1100207Q00000X
NY249399208M00000X
NJ25MA08539700207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG400008746Medicare PIN
NJ168865V07Medicare PIN
NJ168865ZEMEMedicare PIN
NYA400020924Medicare PIN
CACB210075Medicare PIN