=====================================================
General NPI Number Information
=====================================================
NPI Number | 1598187650
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ROBERTA S. MALONE M.D.
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/09/2014
-----------------------------------------------------
Last Update Date | 05/22/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8700 CENTRAL AVE 205
-----------------------------------------------------
City | LANDOVER
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 20785-4831
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 240-619-3407
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 634 BROWNS CT SE
-----------------------------------------------------
City | WASHINGTON
-----------------------------------------------------
State | DC
-----------------------------------------------------
Zip | 20003-1231
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 202-393-1967
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number | MD21207
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------