Basic Information
Provider Information | |||||||||
NPI: | 1477118172 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MALMBERG | ||||||||
FirstName: | IFEOLUWA | ||||||||
MiddleName: | REGINA | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | MD | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | OSUNDARE | ||||||||
OtherFirstName: | IFEOLUWA | ||||||||
OtherMiddleName: | REGINA | ||||||||
OtherNamePrefix: | DR. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | MD | ||||||||
OtherLastNameType: | 1 | ||||||||
Mailing Information | |||||||||
Address1: | 7900 CAMBRIDGE ST APT 15-2C | ||||||||
Address2: |   | ||||||||
City: | HOUSTON | ||||||||
State: | TX | ||||||||
PostalCode: | 770545553 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1500 LANSDOWNE AVE | ||||||||
Address2: |   | ||||||||
City: | DARBY | ||||||||
State: | PA | ||||||||
PostalCode: | 190231200 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6102374000 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/08/2019 | ||||||||
LastUpdateDate: | 07/13/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/13/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 390200000X | MT217387 | PA | Y |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   |
No ID Information.