Provider Demographics
NPI:1285043430
Name:MALLON, ANDREW (DPT)
Entity Type:Individual
Prefix:
First Name:ANDREW
Middle Name:
Last Name:MALLON
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:273 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:ATCO
Mailing Address - State:NJ
Mailing Address - Zip Code:08004-1958
Mailing Address - Country:US
Mailing Address - Phone:856-237-4703
Mailing Address - Fax:
Practice Address - Street 1:273 FRONT ST
Practice Address - Street 2:
Practice Address - City:ATCO
Practice Address - State:NJ
Practice Address - Zip Code:08004-1958
Practice Address - Country:US
Practice Address - Phone:856-237-4703
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-08-12
Last Update Date:2017-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01559600225100000X, 174400000X
2251S0007X, 2251X0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No2251S0007XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistSports
No2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ077873Medicare PIN