Basic Information
| Provider Information | |||||||||
| NPI: | 1871646810 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MALLYA | ||||||||
| FirstName: | ULLAL | ||||||||
| MiddleName: | L | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 14193 DAY FARM RD | ||||||||
| Address2: | |||||||||
| City: | GLENELG | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217379515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4104894882 | ||||||||
| FaxNumber: | 4108716808 | ||||||||
| Practice Location | |||||||||
| Address1: | 14193 DAY FARM RD | ||||||||
| Address2: | |||||||||
| City: | GLENELG | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217379515 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4104894882 | ||||||||
| FaxNumber: | 4108716808 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2007 | ||||||||
| LastUpdateDate: | 10/04/2011 | ||||||||
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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 | 2084P0800X | D0016247 | MD | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.