Basic Information
Provider Information | |||||||||
NPI: | 1346534302 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MALLA | ||||||||
FirstName: | SUNITHA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 370 HWY 121 | ||||||||
Address2: | SUITE 100 | ||||||||
City: | COPPELL | ||||||||
State: | TX | ||||||||
PostalCode: | 75019 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9723825761 | ||||||||
FaxNumber: | 9729541734 | ||||||||
Practice Location | |||||||||
Address1: | 135 RIVER NORTH BLVD | ||||||||
Address2: |   | ||||||||
City: | STEPHENVILLE | ||||||||
State: | TX | ||||||||
PostalCode: | 764011804 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2549652810 | ||||||||
FaxNumber: | 2549655440 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/07/2011 | ||||||||
LastUpdateDate: | 07/01/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/24/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | P8501 | TX | Y |   | Allopathic & Osteopathic Physicians | Family Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 284574501 | 05 | TX |   | MEDICAID | P8501 | 01 |   | TEXAS LICENSE | OTHER |