Provider Demographics
NPI:1861447427
Name:THENAPPAN, MALA (MD)
Entity Type:Individual
Prefix:
First Name:MALA
Middle Name:
Last Name:THENAPPAN
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 1:3070 N 51ST ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53210-1645
Mailing Address - Country:US
Mailing Address - Phone:414-875-9950
Mailing Address - Fax:414-447-2575
Practice Address - Street 1:3070 N 51ST ST
Practice Address - Street 2:SUITE 100
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53210-1645
Practice Address - Country:US
Practice Address - Phone:414-875-9950
Practice Address - Fax:414-447-2575
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-23
Last Update Date:2024-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI36822-020208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32430500Medicaid
WI000101919Medicare ID - Type Unspecified
WI32430500Medicaid