Healthcare Provider Details

I. General information

NPI: 1528592110
Provider Name (Legal Business Name): DEEP MALA MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2017
Last Update Date: 04/20/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 FRONT ST
BINGHAMTON NY
13905-2474
US

IV. Provider business mailing address

225 FRONT ST
BINGHAMTON NY
13905-2474
US

V. Phone/Fax

Practice location:
  • Phone: 607-778-3930
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: