Provider Demographics
NPI:1043652290
Name:MALL, PRERNA ALFA (DPM)
Entity type:Individual
Prefix:
First Name:PRERNA
Middle Name:ALFA
Last Name:MALL
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:408 S 1ST ST
Mailing Address - Street 2:
Mailing Address - City:LAKE WALES
Mailing Address - State:FL
Mailing Address - Zip Code:33853-4146
Mailing Address - Country:US
Mailing Address - Phone:863-676-1710
Mailing Address - Fax:
Practice Address - Street 1:408 S 1ST ST
Practice Address - Street 2:
Practice Address - City:LAKE WALES
Practice Address - State:FL
Practice Address - Zip Code:33853-4146
Practice Address - Country:US
Practice Address - Phone:863-676-1710
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-29
Last Update Date:2017-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO3830213ES0103X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery