Provider Demographics
NPI:1144424862
Name:MALONZO, MARIO SUPAN (MD)
Entity Type:Individual
Prefix:DR
First Name:MARIO
Middle Name:SUPAN
Last Name:MALONZO
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 1:56 WALWORTH AVE
Mailing Address - Street 2:
Mailing Address - City:SCARSDALE
Mailing Address - State:NY
Mailing Address - Zip Code:10583-1423
Mailing Address - Country:US
Mailing Address - Phone:914-725-0751
Mailing Address - Fax:914-722-1730
Practice Address - Street 1:1012 E GUN HILL RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10469-3720
Practice Address - Country:US
Practice Address - Phone:718-918-8850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY152890208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00898540Medicaid
NY00898540Medicaid