Healthcare Provider Details

I. General information

NPI: 1194145920
Provider Name (Legal Business Name): MALA KOKILA KRISHNAMOORTHY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2014
Last Update Date: 02/11/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 W MACARTHUR BLVD
OAKLAND CA
94611-5642
US

IV. Provider business mailing address

2500 MERCED ST
SAN LEANDRO CA
94577-4201
US

V. Phone/Fax

Practice location:
  • Phone: 774-232-1549
  • Fax:
Mailing address:
  • Phone: 510-914-7874
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License Number140784
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: