Healthcare Provider Details

I. General information

NPI: 1205817525
Provider Name (Legal Business Name): YOGESH B MALLA M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/14/2005
Last Update Date: 09/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2831 LONE OAK RD
PADUCAH KY
42003-8041
US

IV. Provider business mailing address

2831 LONE OAK RD
PADUCAH KY
42003-8041
US

V. Phone/Fax

Practice location:
  • Phone: 270-554-8373
  • Fax: 270-554-8987
Mailing address:
  • Phone: 270-554-8373
  • Fax: 270-554-8987

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number38503
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number38503
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number036112552
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: