Provider Demographics
NPI:1073755963
Name:BRIAN J MALLETTE DPM LLC
Entity Type:Organization
Organization Name:BRIAN J MALLETTE DPM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:J
Authorized Official - Last Name:MALLETTE
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:321-728-0117
Mailing Address - Street 1:200 S HARBOR CITY BLVD
Mailing Address - Street 2:SUITE302
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-1384
Mailing Address - Country:US
Mailing Address - Phone:321-728-0117
Mailing Address - Fax:321-728-0151
Practice Address - Street 1:200 S HARBOR CITY BLVD
Practice Address - Street 2:SUITE302
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-1384
Practice Address - Country:US
Practice Address - Phone:321-728-0117
Practice Address - Fax:321-728-0151
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-24
Last Update Date:2015-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2692213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLU73392Medicare UPIN
FL6234080001Medicare NSC
FLE1878XMedicare PIN