Provider Demographics
NPI:1700813524
Name:MALLA, ANANTA (MD)
Entity type:Individual
Prefix:
First Name:ANANTA
Middle Name:
Last Name:MALLA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1521 CURTIS AVE
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-7020
Mailing Address - Country:US
Mailing Address - Phone:310-374-6419
Mailing Address - Fax:310-214-9745
Practice Address - Street 1:3565 DEL AMO BLVD
Practice Address - Street 2:
Practice Address - City:TORRANCE
Practice Address - State:CA
Practice Address - Zip Code:90503-1637
Practice Address - Country:US
Practice Address - Phone:310-370-9031
Practice Address - Fax:310-214-9475
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2012-11-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA40307208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics