Provider Demographics
NPI:1205831914
Name:MALLETTE, ROBERT A (MD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:A
Last Name:MALLETTE
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 1:1200 N STATE ST STE 330
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-2027
Mailing Address - Country:US
Mailing Address - Phone:601-353-2020
Mailing Address - Fax:601-714-5110
Practice Address - Street 1:1200 N STATE ST STE 330
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202
Practice Address - Country:US
Practice Address - Phone:601-353-2020
Practice Address - Fax:601-714-5110
Is Sole Proprietor?:No
Enumeration Date:2005-06-17
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS09632207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS1381951Medicaid
LA1381951Medicaid
AL529921670Medicaid
AL009976305Medicaid
MS180000328Medicare ID - Type UnspecifiedMEDICARE
AL529921670Medicaid
AL009976305Medicaid