Healthcare Provider Details

I. General information

NPI: 1629064845
Provider Name (Legal Business Name): JOHN MALLOY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 09/22/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 S 27TH ST
BILLINGS MT
59101-4200
US

IV. Provider business mailing address

24 GOLD PAN LN
BILLINGS MT
59105-1610
US

V. Phone/Fax

Practice location:
  • Phone: 406-247-3350
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number4839
License Number StateMT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: