Provider Demographics
NPI:1366647513
Name:MALONE, JOHN TERRENCE
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:TERRENCE
Last Name:MALONE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1617 BROADWAY ST
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94590-2406
Mailing Address - Country:US
Mailing Address - Phone:707-556-3794
Mailing Address - Fax:
Practice Address - Street 1:1617 BROADWAY ST
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94590-2406
Practice Address - Country:US
Practice Address - Phone:707-556-3794
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA28700207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine