Healthcare Provider Details

I. General information

NPI: 1821096132
Provider Name (Legal Business Name): TIMOTHY JOHN MALY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2005
Last Update Date: 07/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2005 BLUE MOUNTAIN AVE
BERTHOUD CO
80513-8629
US

IV. Provider business mailing address

1627 E 18TH ST
LOVELAND CO
80538-4209
US

V. Phone/Fax

Practice location:
  • Phone: 970-218-7081
  • Fax:
Mailing address:
  • Phone: 970-663-0135
  • Fax: 970-461-1422

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number31279
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: