Provider Demographics
NPI:1083655443
Name:MALLEY, ROMAN B (MD)
Entity Type:Individual
Prefix:MR
First Name:ROMAN
Middle Name:B
Last Name: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 1:4770 W HERNDON AVE
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93722-8402
Mailing Address - Country:US
Mailing Address - Phone:559-271-6365
Mailing Address - Fax:559-271-6326
Practice Address - Street 1:4770 W HERNDON AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93722-8402
Practice Address - Country:US
Practice Address - Phone:559-271-6365
Practice Address - Fax:559-271-6326
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2007-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA62423207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A624230Medicaid
CA00A624230Medicaid
G66755Medicare UPIN