Healthcare Provider Details

I. General information

NPI: 1275582348
Provider Name (Legal Business Name): JOHN WILLIAM MALO MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 07/24/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2828 CHICAGO AVE STE 400
MINNEAPOLIS MN
55407-1544
US

IV. Provider business mailing address

2828 CHICAGO AVE STE 400
MINNEAPOLIS MN
55407-1544
US

V. Phone/Fax

Practice location:
  • Phone: 612-863-5390
  • Fax: 612-863-2697
Mailing address:
  • Phone: 612-863-5390
  • Fax: 612-863-2697

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VE0102X
TaxonomyReproductive Endocrinology Physician
License Number23884
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: