Healthcare Provider Details

I. General information

NPI: 1083646798
Provider Name (Legal Business Name): JOHN ROBERT MALLOY JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 08/21/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 FLYNN AVE
BURLINGTON VT
05401-5301
US

IV. Provider business mailing address

1589 PRINDLE RD
CHARLOTTE VT
05445-9180
US

V. Phone/Fax

Practice location:
  • Phone: 802-658-0400
  • Fax:
Mailing address:
  • Phone: 802-425-5442
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number042-0008866
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: