Provider Demographics
NPI:1285663609
Name:MALLOW, ERIC B (MD)
Entity Type:Individual
Prefix:
First Name:ERIC
Middle Name:B
Last Name:MALLOW
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 1:235 W 102ND ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10025-8400
Mailing Address - Country:US
Mailing Address - Phone:443-825-6046
Mailing Address - Fax:
Practice Address - Street 1:235 W 102ND ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-8400
Practice Address - Country:US
Practice Address - Phone:443-825-6046
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-30
Last Update Date:2017-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD041201E2080N0001X
NY1819322080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA811264Medicare ID - Type Unspecified
G25595Medicare UPIN
PA811264Medicare ID - Type Unspecified
G25595Medicare UPIN