Provider Demographics
NPI:1033297338
Name:DR. MARIO S. MALONZO, M.D., P.C.
Entity Type:Organization
Organization Name:DR. MARIO S. MALONZO, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:MARIO
Authorized Official - Middle Name:SUPAN
Authorized Official - Last Name:MALONZO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-597-5450
Mailing Address - Street 1:56 WALWORTH AVE
Mailing Address - Street 2:
Mailing Address - City:SCARSDALE
Mailing Address - State:NY
Mailing Address - Zip Code:10583-1423
Mailing Address - Country:US
Mailing Address - Phone:914-725-0751
Mailing Address - Fax:914-722-1730
Practice Address - Street 1:1386 WHITE PLAINS RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10462-4102
Practice Address - Country:US
Practice Address - Phone:718-597-5450
Practice Address - Fax:914-722-1730
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-02
Last Update Date:2008-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY152890208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00898540Medicaid
B78966Medicare UPIN