Healthcare Provider Details

I. General information

NPI: 1417155284
Provider Name (Legal Business Name): STEPHEN M MALOFF MD PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1950 E CLARK STREET SUITE A
POCATELLO ID
83205
US

IV. Provider business mailing address

PO BOX 4948 1950 E CLARK STREET SUITE A
POCATELLO ID
83205
US

V. Phone/Fax

Practice location:
  • Phone: 208-232-5550
  • Fax: 208-232-5553
Mailing address:
  • Phone: 208-232-5550
  • Fax: 208-232-5553

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: STEPHEN M MALOFF
Title or Position: PHYSICIAN
Credential: MD
Phone: 208-232-5550