Healthcare Provider Details

I. General information

NPI: 1316059280
Provider Name (Legal Business Name): STEPHEN M MALOFF MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 11/25/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2240 E CENTER ST
POCATELLO ID
83201
US

IV. Provider business mailing address

2240 E CENTER ST
POCATELLO ID
83201
US

V. Phone/Fax

Practice location:
  • Phone: 208-233-8344
  • Fax: 208-233-6983
Mailing address:
  • Phone: 208-233-8344
  • Fax: 208-233-6983

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2082S0099X
TaxonomyPlastic Surgery Within the Head and Neck (Plastic Surgery) Physician
License NumberM3508
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: