Provider Demographics
NPI:1003839648
Name:MALLEY, STEPHEN DOUGLAS (MD)
Entity Type:Individual
Prefix:MR
First Name:STEPHEN
Middle Name:DOUGLAS
Last Name:MALLEY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5820 LAMAR AVE STE 200
Mailing Address - Street 2:
Mailing Address - City:MISSION
Mailing Address - State:KS
Mailing Address - Zip Code:66202-2655
Mailing Address - Country:US
Mailing Address - Phone:913-492-2530
Mailing Address - Fax:913-492-2576
Practice Address - Street 1:5820 LAMAR AVE STE 200
Practice Address - Street 2:
Practice Address - City:MISSION
Practice Address - State:KS
Practice Address - Zip Code:66202-2655
Practice Address - Country:US
Practice Address - Phone:913-492-2530
Practice Address - Fax:913-492-2576
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS0430173174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KSG97454Medicare UPIN