Provider Demographics
NPI:1265636955
Name:MALLETTE DERMATOLOGY
Entity Type:Organization
Organization Name:MALLETTE DERMATOLOGY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:STEPHEN
Authorized Official - Middle Name:G
Authorized Official - Last Name:MALLETTE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:256-771-1995
Mailing Address - Street 1:707 HWY 31 S
Mailing Address - Street 2:SUITE F
Mailing Address - City:ATHENS
Mailing Address - State:AL
Mailing Address - Zip Code:35611
Mailing Address - Country:US
Mailing Address - Phone:256-771-1995
Mailing Address - Fax:256-771-1965
Practice Address - Street 1:707 HWY 31 S
Practice Address - Street 2:SUITE F
Practice Address - City:ATHENS
Practice Address - State:AL
Practice Address - Zip Code:35611
Practice Address - Country:US
Practice Address - Phone:256-771-1995
Practice Address - Fax:256-771-1965
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-14
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALDO841174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL=========OtherTID
ALI12734Medicare UPIN