Healthcare Provider Details

I. General information

NPI: 1568432862
Provider Name (Legal Business Name): JOHN T MALCYNSKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/26/2006
Last Update Date: 08/27/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2402 FRIST BLVD SUITE 204
FORT PIERCE FL
34950
US

IV. Provider business mailing address

2402 FRIST BLVD SUITE 204
FORT PIERCE FL
34950
US

V. Phone/Fax

Practice location:
  • Phone: 772-462-3939
  • Fax: 772-462-3938
Mailing address:
  • Phone: 772-462-3939
  • Fax: 772-462-3938

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0102X
TaxonomySurgical Critical Care Physician
License NumberME112973
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code2086S0127X
TaxonomyTrauma Surgery Physician
License NumberME112973
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: