Provider Demographics
NPI:1083653646
Name:O'MALLEY, BRIAN (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:
Last Name:O'MALLEY
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 1:30 SHANK PAINTER RD
Mailing Address - Street 2:
Mailing Address - City:PROVINCETOWN
Mailing Address - State:MA
Mailing Address - Zip Code:02657-1342
Mailing Address - Country:US
Mailing Address - Phone:508-487-3505
Mailing Address - Fax:508-487-9023
Practice Address - Street 1:30 SHANK PAINTER RD
Practice Address - Street 2:
Practice Address - City:PROVINCETOWN
Practice Address - State:MA
Practice Address - Zip Code:02657-1342
Practice Address - Country:US
Practice Address - Phone:508-487-3505
Practice Address - Fax:508-487-9023
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2010-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA39544207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAC20239OtherBCBS
MA2080087Medicaid
MAC20239Medicare ID - Type Unspecified
MAC20239OtherBCBS