MEDICARE: WILLIAM J. MALLON, MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332900000X	Non-Pharmacy Dispensing Site

General Provider Information

NPI Number	:	1336906221
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WILLIAM J. MALLON, MD

Provider Business Mailing Address
First Line	:	3500 US HIGHWAY 1
Second Line	:
City	:	VERO BEACH
State	:	FL
Zip	:	32960-4511
Country	:	US
Telephone Number	:	772-299-1404
Fax Number	:

Provider Business Practice Location Address
First Line	:	1707 S 25TH ST
Second Line	:
City	:	FORT PIERCE
State	:	FL
Zip	:	34947-4709
Country	:	US
Telephone Number	:	772-299-1404
Fax Number	:

Authorized Official
Title or Position	:	RPHT
Name	:	MICHELLE MALCOLM
Credential	:
Telephone Number	:	772-299-1404

Provider Enumeration Date	:	03/06/2024
Last Update Date	:	03/06/2024

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