Healthcare Provider Details

I. General information

NPI: 1902893134
Provider Name (Legal Business Name): JAY V MALICKEL D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/03/2005
Last Update Date: 09/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

798 CENTERTON RD
ELMER NJ
08318-3945
US

IV. Provider business mailing address

PO BOX 2284
VINELAND NJ
08362-2284
US

V. Phone/Fax

Practice location:
  • Phone: 856-358-6161
  • Fax: 856-358-0142
Mailing address:
  • Phone: 856-358-6161
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMB06869400
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: