Provider Demographics
NPI:1245412295
Name:MALLO, GREGORY CHARLES (MD)
Entity Type:Individual
Prefix:DR
First Name:GREGORY
Middle Name:CHARLES
Last Name:MALLO
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:6 TECHNOLOGY DR 100
Mailing Address - Street 2:
Mailing Address - City:EAST SETAUKET
Mailing Address - State:NY
Mailing Address - Zip Code:11733-4079
Mailing Address - Country:US
Mailing Address - Phone:631-689-6698
Mailing Address - Fax:631-751-5548
Practice Address - Street 1:6 TECHNOLOGY DR 100
Practice Address - Street 2:
Practice Address - City:EAST SETAUKET
Practice Address - State:NY
Practice Address - Zip Code:11733-4079
Practice Address - Country:US
Practice Address - Phone:631-689-6698
Practice Address - Fax:631-751-5548
Is Sole Proprietor?:No
Enumeration Date:2007-12-01
Last Update Date:2015-11-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY280603207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
1245412295Medicare UPIN