Provider Demographics
NPI:1306842232
Name:MALAN, JON DANIEL (DO)
Entity Type:Individual
Prefix:
First Name:JON
Middle Name:DANIEL
Last Name:MALAN
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 S 11TH AVE STE 400
Mailing Address - Street 2:
Mailing Address - City:POCATELLO
Mailing Address - State:ID
Mailing Address - Zip Code:83201-4880
Mailing Address - Country:US
Mailing Address - Phone:208-232-7862
Mailing Address - Fax:208-232-4869
Practice Address - Street 1:1001 N 7TH AVE STE 135
Practice Address - Street 2:
Practice Address - City:POCATELLO
Practice Address - State:ID
Practice Address - Zip Code:83201-5790
Practice Address - Country:US
Practice Address - Phone:208-425-2489
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-24
Last Update Date:2024-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8092207Q00000X
IDO-1510207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAI13033Medicare UPIN