Healthcare Provider Details

I. General information

NPI: 1427037951
Provider Name (Legal Business Name): JOHN KENNETH MALLEN MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/12/2006
Last Update Date: 09/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32 STILES RD STE 204
SALEM NH
03079
US

IV. Provider business mailing address

32 STILES RD STE 204
SALEM NH
03079
US

V. Phone/Fax

Practice location:
  • Phone: 603-894-9898
  • Fax: 603-894-6270
Mailing address:
  • Phone: 603-894-9898
  • Fax: 603-894-6270

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number10052
License Number StateNH
# 2
Primary TaxonomyN
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number154434
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: