Healthcare Provider Details

I. General information

NPI: 1427099159
Provider Name (Legal Business Name): ANUPAMA VALLALA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 08/04/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2 TERMINAL DR SUITE 8
EAST ALTON IL
62024-2201
US

IV. Provider business mailing address

2 TERMINAL DR SUITE 8
EAST ALTON IL
62024-2201
US

V. Phone/Fax

Practice location:
  • Phone: 618-259-1419
  • Fax: 618-259-1502
Mailing address:
  • Phone: 618-259-1419
  • Fax: 618-259-1502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036112205
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: