Provider Demographics
NPI:1023581980
Name:MALLA, RANENDRA PRATAP
Entity type:Individual
Prefix:
First Name:RANENDRA
Middle Name:PRATAP
Last Name:MALLA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3422 57TH ST FL 1
Mailing Address - Street 2:
Mailing Address - City:WOODSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11377-2124
Mailing Address - Country:US
Mailing Address - Phone:347-965-6607
Mailing Address - Fax:
Practice Address - Street 1:3422 57TH ST FL 1
Practice Address - Street 2:
Practice Address - City:WOODSIDE
Practice Address - State:NY
Practice Address - Zip Code:11377-2124
Practice Address - Country:US
Practice Address - Phone:347-965-6607
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-03
Last Update Date:2019-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171W00000XOther Service ProvidersContractorGroup - Single Specialty