Provider Demographics
NPI:1043272396
Name:MALONEY, JACK EDWARD (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:EDWARD
Last Name:MALONEY
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 1:788 N. JEFFERSON STREET
Mailing Address - Street 2:SUITE 300/ATTN KAAREN BUTZEN
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-3710
Mailing Address - Country:US
Mailing Address - Phone:414-272-8950
Mailing Address - Fax:414-272-0859
Practice Address - Street 1:2323 S 102ND ST
Practice Address - Street 2:
Practice Address - City:WEST ALLIS
Practice Address - State:WI
Practice Address - Zip Code:53227-2103
Practice Address - Country:US
Practice Address - Phone:414-541-9900
Practice Address - Fax:414-329-2238
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2016-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI44691207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1043272396Medicaid
WI003573645Medicare PIN
WI002646210Medicare PIN