Healthcare Provider Details

I. General information

NPI: 1669649729
Provider Name (Legal Business Name): PRASHANTH A MALLY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2008
Last Update Date: 11/23/2021
Certification Date: 11/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12255 FAIR LAKES PKWY
FAIRFAX VA
22033-3952
US

IV. Provider business mailing address

2101 E JEFFERSON ST KAISER PERMANENTE MEDICARE ENROLLMENT
ROCKVILLE MD
20852-4908
US

V. Phone/Fax

Practice location:
  • Phone: 703-934-5700
  • Fax:
Mailing address:
  • Phone: 301-816-2424
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number101244719
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: