Healthcare Provider Details

I. General information

NPI: 1447450424
Provider Name (Legal Business Name): JOHN PATRICK MALLOY IV DO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2007
Last Update Date: 11/27/2021
Certification Date: 11/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4515 WILES RD STE 201
COCONUT CREEK FL
33073-3414
US

IV. Provider business mailing address

2225 SW 14TH PL
BOCA RATON FL
33486-8558
US

V. Phone/Fax

Practice location:
  • Phone: 954-500-4554
  • Fax: 954-400-0904
Mailing address:
  • Phone: 954-500-4554
  • Fax: 954-400-0904

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberOS014015
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberOT011278
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberH70338
License Number StateMD
# 4
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License NumberOS11281
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: