Basic Information
| Provider Information | |||||||||
| NPI: | 1184682411 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MILAM | ||||||||
| FirstName: | MALLORY | ||||||||
| MiddleName: | STANTON | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5486 | ||||||||
| Address2: | |||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928635486 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8185500900 | ||||||||
| FaxNumber: | 8185500900 | ||||||||
| Practice Location | |||||||||
| Address1: | 16055 VENTURA BLVD STE 120 | ||||||||
| Address2: | |||||||||
| City: | ENCINO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 914362635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4244997124 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/03/2006 | ||||||||
| LastUpdateDate: | 05/16/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/16/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207L00000X | A78479 | CA | Y | Allopathic & Osteopathic Physicians | Anesthesiology |
No ID Information.