Provider Demographics
NPI:1033200514
Name:MALACHOWSKI, JON CHARLES (MD)
Entity Type:Individual
Prefix:DR
First Name:JON
Middle Name:CHARLES
Last Name:MALACHOWSKI
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 1:1010 N SEPULVEDA BLVD
Mailing Address - Street 2:
Mailing Address - City:MANHATTAN BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90266-5929
Mailing Address - Country:US
Mailing Address - Phone:310-376-6262
Mailing Address - Fax:310-376-8228
Practice Address - Street 1:1010 N SEPULVEDA BLVD
Practice Address - Street 2:
Practice Address - City:MANHATTAN BEACH
Practice Address - State:CA
Practice Address - Zip Code:90266-5929
Practice Address - Country:US
Practice Address - Phone:310-376-6262
Practice Address - Fax:310-376-8228
Is Sole Proprietor?:No
Enumeration Date:2006-09-27
Last Update Date:2013-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA52494207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR100222Medicaid
08WCHQRWMedicare ID - Type Unspecified
OR100222Medicaid