MEDICARE: JAMIE A MALLAH MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208000000X	Pediatrics Physician	ME98703	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1245421403
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAMIE A MALLAH MD

Provider Business Mailing Address
First Line	:	4902 EISENHOWER BLVD
Second Line	:	SUITE 300
City	:	TAMPA
State	:	FL
Zip	:	33634-6344
Country	:	US
Telephone Number	:	813-636-2000
Fax Number	:	813-286-8835

Provider Business Practice Location Address
First Line	:	4683 VAN DYKE RD
Second Line	:
City	:	LUTZ
State	:	FL
Zip	:	33558-4880
Country	:	US
Telephone Number	:	813-968-7171
Fax Number	:	813-968-7282

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/05/2007
Last Update Date	:	09/21/2011

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Directions to “ JAMIE A MALLAH MD” Practice Location

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