Healthcare Provider Details

I. General information

NPI: 1083714919
Provider Name (Legal Business Name): GAGAN DEEP MALL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: GAGAN DEEP RAM M.D.

II. Dates (important events)

Enumeration Date: 09/22/2006
Last Update Date: 07/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2100 NAPA VALLEJO HWY
NAPA CA
94558-6234
US

IV. Provider business mailing address

596 EDENDERRY DR
VACAVILLE CA
95688-8560
US

V. Phone/Fax

Practice location:
  • Phone: 707-253-5434
  • Fax: 707-254-2423
Mailing address:
  • Phone: 707-392-5086
  • Fax: 707-392-5086

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number22370
License Number StateOK
# 2
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number22370
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: