Provider Demographics
NPI:1144222860
Name:O'MALLEY, JOHN S (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:S
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 1:2716 ASHTON DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28412-2489
Mailing Address - Country:US
Mailing Address - Phone:910-332-3800
Mailing Address - Fax:910-251-0421
Practice Address - Street 1:2716 ASHTON DR
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28412-2489
Practice Address - Country:US
Practice Address - Phone:910-332-3800
Practice Address - Fax:910-251-0421
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2022-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC009300261207X00000X
NC9300261207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
No207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8964172Medicaid
NC009300261OtherMEDICAL LICENSE
NC009300261OtherMEDICAL LICENSE
NC2191027AMedicare ID - Type UnspecifiedMEDICARE