Basic Information
| Provider Information | |||||||||
| NPI: | 1770666208 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MALVIYA | ||||||||
| FirstName: | PRAKASH | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 409 COTTAGE ROAD | ||||||||
| Address2: | ETMC | ||||||||
| City: | CARTHAGE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9036944790 | ||||||||
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| Practice Location | |||||||||
| Address1: | 409 COTTAGE ROAD | ||||||||
| Address2: | ETMC | ||||||||
| City: | CARTHAGE | ||||||||
| State: | TX | ||||||||
| PostalCode: | 75633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9036944790 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2006 | ||||||||
| LastUpdateDate: | 03/11/2011 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | 189949 | NY | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | CAREPLUS | 01 | NY | 189949 | OTHER | 01553277 | 05 | NY | MEDICAID |