Healthcare Provider Details

I. General information

NPI: 1700870086
Provider Name (Legal Business Name): PRADEEP MALLY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2005
Last Update Date: 02/23/2021
Certification Date: 02/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 1ST AVE 7 A
NEW YORK NY
10016-6402
US

IV. Provider business mailing address

530 1ST AVE 7 A
NEW YORK NY
10016-6402
US

V. Phone/Fax

Practice location:
  • Phone: 212-263-7477
  • Fax:
Mailing address:
  • Phone: 212-263-7477
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080N0001X
TaxonomyNeonatal-Perinatal Medicine Physician
License Number218568
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: