Healthcare Provider Details

I. General information

NPI: 1144424862
Provider Name (Legal Business Name): MARIO SUPAN MALONZO M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/14/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1012 E GUN HILL RD
BRONX NY
10469-3720
US

IV. Provider business mailing address

56 WALWORTH AVE
SCARSDALE NY
10583-1423
US

V. Phone/Fax

Practice location:
  • Phone: 718-918-8850
  • Fax:
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:
Title or Position:
Credential:
Phone: