Provider Demographics
NPI:1700937158
Name:MALLYA, RAZIYA (MD)
Entity type:Individual
Prefix:
First Name:RAZIYA
Middle Name:
Last Name:MALLYA
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 1:1129 MACKLIND AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1440
Mailing Address - Country:US
Mailing Address - Phone:314-534-0200
Mailing Address - Fax:314-534-7996
Practice Address - Street 1:1129 MACKLIND AVE
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1440
Practice Address - Country:US
Practice Address - Phone:314-534-0200
Practice Address - Fax:314-534-7996
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MOR7932207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine