Healthcare Provider Details

I. General information

NPI: 1417047515
Provider Name (Legal Business Name): MR. CARL HUBERT MALONE JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2006
Last Update Date: 08/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4540 SHERWOOD WAY SUITE 104A
SAN ANGELO TX
76901-5619
US

IV. Provider business mailing address

PO BOX 60251
SAN ANGELO TX
76906-0251
US

V. Phone/Fax

Practice location:
  • Phone: 325-947-1505
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4293T
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: