MEDICARE: PRESTON W MALL 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	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1316525058
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	PRESTON W MALL MD

Provider Business Mailing Address
First Line	:	439 WOODGATE BLVD
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70808-5423
Country	:	US
Telephone Number	:	225-978-9733
Fax Number	:

Provider Business Practice Location Address
First Line	:	439 WOODGATE BLVD
Second Line	:
City	:	BATON ROUGE
State	:	LA
Zip	:	70808-5423
Country	:	US
Telephone Number	:	225-978-9733
Fax Number	:

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

Provider Enumeration Date	:	04/01/2021
Last Update Date	:	04/01/2021

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