Healthcare Provider Details

I. General information

NPI: 1265224190
Provider Name (Legal Business Name): JOSHUA SHANE MALLON OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2025
Last Update Date: 05/28/2025
Certification Date: 05/28/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3200 S UNIVERSITY DR
DAVIE FL
33328-2018
US

IV. Provider business mailing address

3200 S UNIVERSITY DR
DAVIE FL
33328-2018
US

V. Phone/Fax

Practice location:
  • Phone: 954-262-4200
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number14223901-9934
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: