Healthcare Provider Details

I. General information

NPI: 1962436360
Provider Name (Legal Business Name): STEPHEN M MALLON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 05/08/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 NW 12TH AVE
MIAMI FL
33136-1005
US

IV. Provider business mailing address

1500 NW 12TH AVE JMT-EAST 1004
MIAMI FL
33136-1028
US

V. Phone/Fax

Practice location:
  • Phone: 305-585-1111
  • Fax: 305-585-6960
Mailing address:
  • Phone: 305-585-6779
  • Fax: 305-585-6960

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberME12372
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: