Healthcare Provider Details

I. General information

NPI: 1134816168
Provider Name (Legal Business Name): MIA MALVESTUTO DO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/19/2023
Last Update Date: 09/11/2026
Certification Date: 09/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8975 BALBOA AVE
SAN DIEGO CA
92123-1507
US

IV. Provider business mailing address

8975 BALBOA AVE
SAN DIEGO CA
92123-1507
US

V. Phone/Fax

Practice location:
  • Phone: 858-499-2600
  • Fax:
Mailing address:
  • Phone: 858-499-2600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number20A24550
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: