Healthcare Provider Details

I. General information

NPI: 1194862219
Provider Name (Legal Business Name): JOHN DANIEL MALAN AUD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 12/19/2019
Certification Date: 12/19/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 SIMI TOWN CENTER WAY STE 3
SIMI VALLEY CA
93065-8408
US

IV. Provider business mailing address

1717 SIMI TOWN CENTER WAY STE 3
SIMI VALLEY CA
93065-8408
US

V. Phone/Fax

Practice location:
  • Phone: 805-579-9324
  • Fax: 805-579-9647
Mailing address:
  • Phone: 805-579-9324
  • Fax: 805-579-9647

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code237600000X
TaxonomyAudiologist-Hearing Aid Fitter
License NumberAU1728
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code231H00000X
TaxonomyAudiologist
License NumberAU1728
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: