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General NPI Number Information
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NPI Number | 1144424862
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Entity Type | Individual
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Provider Name | MARIO SUPAN MALONZO M.D.
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Gender | Male
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Dates
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Enumeration Date | 06/14/2007
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Last Update Date | 07/08/2007
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Provider Practice Location Address
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Address Line | 1012 E GUN HILL RD
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City | BRONX
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State | NY
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Zip | 10469-3720
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Country | US
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Telephone | 718-918-8850
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Fax |
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Provider Business Mailing Address
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Address Line | 56 WALWORTH AVE
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City | SCARSDALE
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State | NY
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Zip | 10583-1423
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Country | US
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Telephone | 914-725-0751
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Fax | 914-722-1730
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 152890
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License Number State | NY
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