Healthcare Provider Details

I. General information

NPI: 1104873116
Provider Name (Legal Business Name): ASHOK R MALLYA MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 05/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 N GRAND BLVD
SAINT LOUIS MO
63106-1621
US

IV. Provider business mailing address

12515 WINDMOOR PL
SAINT LOUIS MO
63131-3019
US

V. Phone/Fax

Practice location:
  • Phone: 314-652-4100
  • Fax:
Mailing address:
  • Phone: 314-652-4100
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084A0401X
TaxonomyAddiction Medicine (Psychiatry & Neurology) Physician
License NumberR6991
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: