Doctor Name: | ASHOK R MALLYA |
NPI Number: | 1104873116 |
Entity Type Code: | Individual (1) |
Gender: | M |
Credentials: | MD |
License Number: | R6991 |
Business Practice Address: | 915 N Grand Blvd Saint Louis, MO - 631061621 |
Business Phone Number: | 3146524100 |
Business Fax Number: | |
Mailing Address: | 12515 Windmoor Pl, SAINT LOUIS |
State: | MO |
Postal Code: | 631313019 |
Phone Number: | 3146524100 |
Fax Number: | |
NPI Enumeration Date: | 05/27/2006 |
NPI Last Update Date: | 07/08/2007 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 2084A0401X |
License Number: | R6991 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | MO |
Taxonomy Type: | Allopathic & Osteopathic Physicians |
Taxonomy Classification: | Psychiatry & Neurology |
Taxonomy Specialization: | Addiction Medicine |
Taxonomy Definition: | A doctor of osteopathy board eligible/certified in the field of Psychiatry by the American Osteopathic Board of Neurology and Psychiatry is able to obtain a Certificate of Added Qualifications in the field of Addiction Medicine |