Healthcare Provider Details

I. General information

NPI: 1033297338
Provider Name (Legal Business Name): DR. MARIO S. MALONZO, M.D., P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 06/22/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1386 WHITE PLAINS RD
BRONX NY
10462-4102
US

IV. Provider business mailing address

56 WALWORTH AVE
SCARSDALE NY
10583-1423
US

V. Phone/Fax

Practice location:
  • Phone: 718-597-5450
  • Fax: 914-722-1730
Mailing address:
  • Phone: 914-725-0751
  • Fax: 914-722-1730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number152890
License Number StateNY

VIII. Authorized Official

Name: DR. MARIO SUPAN MALONZO
Title or Position: PRESIDENT
Credential: M.D.
Phone: 718-597-5450