Provider Demographics
NPI:1023277670
Name:MALLYA, KIRON (MD)
Entity type:Individual
Prefix:
First Name:KIRON
Middle Name:
Last Name:MALLYA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 62063
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21264-2063
Mailing Address - Country:US
Mailing Address - Phone:410-706-5181
Mailing Address - Fax:410-706-5103
Practice Address - Street 1:22 S GREENE ST
Practice Address - Street 2:PEDIATRICS, N5W56
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-1544
Practice Address - Country:US
Practice Address - Phone:410-328-6662
Practice Address - Fax:410-328-0646
Is Sole Proprietor?:No
Enumeration Date:2008-06-07
Last Update Date:2013-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MDD72659208000000X, 2080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD044129500Medicaid