Healthcare Provider Details

I. General information

NPI: 1649242538
Provider Name (Legal Business Name): DAVID JOEL MALIS MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/03/2006
Last Update Date: 09/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1499 S HARBOR CITY BLVD SUITE 303
MELBOURNE FL
32901-3245
US

IV. Provider business mailing address

1499 S HARBOR CITY BLVD SUITE 303
MELBOURNE FL
32901-3245
US

V. Phone/Fax

Practice location:
  • Phone: 321-254-5437
  • Fax: 321-254-4543
Mailing address:
  • Phone: 321-254-5437
  • Fax: 321-254-4543

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YP0228X
TaxonomyPediatric Otolaryngology Physician
License NumberME90348
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207YX0905X
TaxonomyOtolaryngology/Facial Plastic Surgery Physician
License NumberME90348
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: