Provider Demographics
NPI:1508326562
Name:MALONE, TRUDY (MD)
Entity Type:Individual
Prefix:
First Name:TRUDY
Middle Name:
Last Name:MALONE
Suffix:
Gender:F
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:N30W29293 HILLCREST DR
Mailing Address - Street 2:
Mailing Address - City:PEWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53072-3235
Mailing Address - Country:US
Mailing Address - Phone:262-369-0030
Mailing Address - Fax:
Practice Address - Street 1:N30W29293 HILLCREST DR
Practice Address - Street 2:
Practice Address - City:PEWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53072-3235
Practice Address - Country:US
Practice Address - Phone:262-369-0030
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-24
Last Update Date:2019-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN37377207V00000X
WI39304-20207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI39304-20OtherWISCONSIN MEDICINE AND SURGERY LICENSE