Basic Information
| Provider Information | |||||||||
| NPI: | 1508943432 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MOLLA | ||||||||
| FirstName: | MITHU | ||||||||
| MiddleName: | S. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4150 V STREET, SUITE 3400 | ||||||||
| Address2: | UC DAVIS MEDICAL CENTER, PSSB | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167347506 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4150 V ST | ||||||||
| Address2: | SUITE 3400 | ||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958171460 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167347506 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2006 | ||||||||
| LastUpdateDate: | 08/08/2008 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208M00000X | A81343 | CA | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 00A813430 | 05 | CA | MEDICAID |