Provider Demographics
NPI:1053422204
Name:SHIVA, MALLALAH (MD)
Entity type:Individual
Prefix:DR
First Name:MALLALAH
Middle Name:
Last Name:SHIVA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:PROFESSIONAL
Other - Middle Name:
Other - Last Name:ASSOCIATES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:14094 O'CONNOR RD
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78247
Mailing Address - Country:US
Mailing Address - Phone:210-599-2273
Mailing Address - Fax:210-599-2283
Practice Address - Street 1:14094 O'CONNOR RD
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78247
Practice Address - Country:US
Practice Address - Phone:210-599-2273
Practice Address - Fax:210-599-2283
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXG2619207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
C21768Medicare UPIN
TXD06WMedicare ID - Type Unspecified