Provider Demographics
NPI:1083646798
Name:MALLOY, JOHN ROBERT JR (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:ROBERT
Last Name:MALLOY
Suffix:JR
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 1:1589 PRINDLE RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:VT
Mailing Address - Zip Code:05445-9180
Mailing Address - Country:US
Mailing Address - Phone:802-425-5442
Mailing Address - Fax:
Practice Address - Street 1:300 FLYNN AVE
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:VT
Practice Address - Zip Code:05401-5301
Practice Address - Country:US
Practice Address - Phone:802-658-0400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2009-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VT042-00088662084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
VT0VN0340Medicaid