Provider Demographics
NPI:1083899686
Name:O'MALLEY, MARK ALAN (DO)
Entity Type:Individual
Prefix:DR
First Name:MARK
Middle Name:ALAN
Last Name:O'MALLEY
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 1:4441 E MCDOWELL RD STE 101
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85008-4503
Mailing Address - Country:US
Mailing Address - Phone:602-862-9390
Mailing Address - Fax:
Practice Address - Street 1:4441 E MCDOWELL RD STE 101
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85008-4503
Practice Address - Country:US
Practice Address - Phone:602-862-9390
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-02
Last Update Date:2018-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ3364208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ24246 AZMedicare PIN
AZG86737Medicare UPIN