MEDICARE: MR. CARL HUBERT MALONE JR.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	4293T	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1417047515
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CARL HUBERT MALONE JR.

Provider Business Mailing Address
First Line	:	PO BOX 60251
Second Line	:
City	:	SAN ANGELO
State	:	TX
Zip	:	76906-0251
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4540 SHERWOOD WAY
Second Line	:	SUITE 104A
City	:	SAN ANGELO
State	:	TX
Zip	:	76901-5619
Country	:	US
Telephone Number	:	325-947-1505
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/13/2006
Last Update Date	:	08/08/2012

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