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General NPI Number Information
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NPI Number | 1124252705
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Entity Type | Organization
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Legal Business Name | MARY MALLAVARAPU MD
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Dates
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Enumeration Date | 05/11/2009
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Last Update Date | 05/11/2009
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Provider Practice Location Address
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Address Line | 100 PHILLIPS HILL RD
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City | NEW CITY
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State | NY
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Zip | 10956-4134
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Country | US
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Telephone | 845-634-0068
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Fax |
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Provider Business Mailing Address
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Address Line | 971 ROUTE 45 SUITE 112
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City | POMONA
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State | NY
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Zip | 10970-3500
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Country | US
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Telephone | 845-354-8054
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Fax | 845-354-1807
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Authorized Official
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Title or Position | OFFICE MANAGER
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Name | MS. ANITA SOARES
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Credential | MBA
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Telephone | 845-634-0068
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 121643
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License Number State | NY
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