Provider Demographics
NPI:1821043423
Name:MALL, DOMINIQUE LUCIENNE (MD)
Entity Type:Individual
Prefix:
First Name:DOMINIQUE
Middle Name:LUCIENNE
Last Name:MALL
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:PO BOX 9602
Mailing Address - Street 2:
Mailing Address - City:MISSION HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91346-9602
Mailing Address - Country:US
Mailing Address - Phone:818-837-5637
Mailing Address - Fax:818-837-5589
Practice Address - Street 1:11211 SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:MISSION HILLS
Practice Address - State:CA
Practice Address - Zip Code:91345-1115
Practice Address - Country:US
Practice Address - Phone:818-365-9531
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-23
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA86680207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0A8668000Medicaid
CA0A8668000Medicaid
AZZ145953Medicare PIN
I12589Medicare UPIN
AZZ145955Medicare PIN