Provider Demographics
NPI:1083092241
Name:MALTA, JOHN ROBERT (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ROBERT
Last Name:MALTA
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 MINOT AVE
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:ME
Mailing Address - Zip Code:04210-4900
Mailing Address - Country:US
Mailing Address - Phone:207-795-2927
Mailing Address - Fax:
Practice Address - Street 1:10 MINOT AVE
Practice Address - Street 2:
Practice Address - City:AUBURN
Practice Address - State:ME
Practice Address - Zip Code:04210-4900
Practice Address - Country:US
Practice Address - Phone:207-795-2927
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-08
Last Update Date:2021-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT016535390200000X
MEDO31922084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program