Healthcare Provider Details

I. General information

NPI: 1841393097
Provider Name (Legal Business Name): TYRONE CECIL MALLOY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2006
Last Update Date: 09/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4201 RAINBOW DR
DECATUR GA
30034-2302
US

IV. Provider business mailing address

4201 RAINBOW DR
DECATUR GA
30034-2302
US

V. Phone/Fax

Practice location:
  • Phone: 404-534-0035
  • Fax: 404-286-7100
Mailing address:
  • Phone: 404-534-0035
  • Fax: 404-286-7100

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number23086
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: