Provider Demographics
NPI:1366481954
Name:MALTA, RAYMOND J (DO)
Entity Type:Individual
Prefix:
First Name:RAYMOND
Middle Name:J
Last Name:MALTA
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 1:307 S EVERGREEN AVE
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NJ
Mailing Address - Zip Code:08096-2739
Mailing Address - Country:US
Mailing Address - Phone:856-686-4300
Mailing Address - Fax:
Practice Address - Street 1:2201 CHAPEL AVE W
Practice Address - Street 2:
Practice Address - City:CHERRY HILL
Practice Address - State:NJ
Practice Address - Zip Code:08002-2048
Practice Address - Country:US
Practice Address - Phone:856-488-6816
Practice Address - Fax:856-488-6511
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB59354207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ223586506OtherCHAMPUS/TRICARE
NJ6930204Medicaid
NJ223586506OtherNJBCBS
NJ223586506OtherNJBCBS
NJ6930204Medicaid