Healthcare Provider Details

I. General information

NPI: 1174501555
Provider Name (Legal Business Name): PATRICK S MALONE DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/05/2006
Last Update Date: 04/12/2023
Certification Date: 04/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 J L WHITE DR STE 140B
JASPER GA
30143-4896
US

IV. Provider business mailing address

PO BOX 2589
GAINESVILLE GA
30503-2589
US

V. Phone/Fax

Practice location:
  • Phone: 770-408-2039
  • Fax: 888-325-0461
Mailing address:
  • Phone: 888-821-1242
  • Fax: 888-325-0461

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License Number000833
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License Number000833
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: