Healthcare Provider Details

I. General information

NPI: 1992097612
Provider Name (Legal Business Name): JOHN DAVID MALOUF D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/12/2011
Last Update Date: 08/30/2021
Certification Date: 08/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1219 N 400 E
LOGAN UT
84341-2321
US

IV. Provider business mailing address

2855 N 920 E
NORTH LOGAN UT
84341-5806
US

V. Phone/Fax

Practice location:
  • Phone: 435-565-6043
  • Fax: 435-220-2030
Mailing address:
  • Phone: 435-557-0354
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number5101018972
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number317131-1204
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: