Healthcare Provider Details

I. General information

NPI: 1700813524
Provider Name (Legal Business Name): ANANTA MALLA M.D
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2006
Last Update Date: 11/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3565 DEL AMO BLVD
TORRANCE CA
90503-1637
US

IV. Provider business mailing address

1521 CURTIS AVE
MANHATTAN BEACH CA
90266-7020
US

V. Phone/Fax

Practice location:
  • Phone: 310-370-9031
  • Fax: 310-214-9475
Mailing address:
  • Phone: 310-374-6419
  • Fax: 310-214-9745

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA40307
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: