=====================================================
General NPI Number Information
=====================================================
NPI Number | 1053389361
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KEVIN ANTHONY MALONE MD, MBA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/10/2006
-----------------------------------------------------
Last Update Date | 11/11/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1415 RIDGEBACK RD SUITE # 4
-----------------------------------------------------
City | CHULA VISTA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91910-6932
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-421-6913
-----------------------------------------------------
Fax | 619-421-6913
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1415 RIDGEBACK RD SUITE # 4
-----------------------------------------------------
City | CHULA VISTA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91910-6932
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-421-6913
-----------------------------------------------------
Fax | 619-421-6913
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | G46053
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------