Healthcare Provider Details

I. General information

NPI: 1215584388
Provider Name (Legal Business Name): DEVON MALECKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2019
Last Update Date: 08/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

266 CANYON ACRES DR
LAGUNA BEACH CA
92651-1106
US

IV. Provider business mailing address

266 CANYON ACRES DR
LAGUNA BEACH CA
92651-1106
US

V. Phone/Fax

Practice location:
  • Phone: 949-310-1212
  • Fax:
Mailing address:
  • Phone: 949-310-1212
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberA66636
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: