Provider Demographics
NPI:1033393996
Name:MALLALIEU, JARED EMERSON (DO)
Entity Type:Individual
Prefix:
First Name:JARED
Middle Name:EMERSON
Last Name:MALLALIEU
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:10845 PHILADELPHIA RD
Mailing Address - Street 2:
Mailing Address - City:WHITE MARSH
Mailing Address - State:MD
Mailing Address - Zip Code:21162-1717
Mailing Address - Country:US
Mailing Address - Phone:410-335-0008
Mailing Address - Fax:410-335-3113
Practice Address - Street 1:484 RITCHIE HWY STE A
Practice Address - Street 2:
Practice Address - City:SEVERNA PARK
Practice Address - State:MD
Practice Address - Zip Code:21146-2961
Practice Address - Country:US
Practice Address - Phone:410-544-4600
Practice Address - Fax:410-544-0997
Is Sole Proprietor?:No
Enumeration Date:2007-12-27
Last Update Date:2015-06-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MDH68311208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD95050303OtherCAREFIRST
MD417363500OtherMEDICAL ASSISTANCE
MD1622382ZF69OtherMEDICARE
MD242301OtherJHHC
DCU993 0001OtherCAREFIRST