Provider Demographics
NPI:1306378245
Name:MALONE, CORY (MD)
Entity Type:Individual
Prefix:
First Name:CORY
Middle Name:
Last Name:MALONE
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 1:220 COMPASS POINT DRIVE
Mailing Address - Street 2:
Mailing Address - City:ST CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63301
Mailing Address - Country:US
Mailing Address - Phone:636-947-4480
Mailing Address - Fax:636-947-9860
Practice Address - Street 1:300 FIRST CAPITOL DRIVE
Practice Address - Street 2:
Practice Address - City:ST CHARLES
Practice Address - State:MO
Practice Address - Zip Code:63301
Practice Address - Country:US
Practice Address - Phone:636-947-5444
Practice Address - Fax:636-947-5259
Is Sole Proprietor?:No
Enumeration Date:2017-03-30
Last Update Date:2023-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILM45010188321390200000X
MO20230147172085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200125501Medicaid