Provider Demographics
NPI:1518996412
Name:MALZONE, MEGAN M (MD)
Entity Type:Individual
Prefix:
First Name:MEGAN
Middle Name:M
Last Name:MALZONE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MEGAN
Other - Middle Name:
Other - Last Name:ELLMAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:931 OAK PARK BLVD STE 101
Mailing Address - Street 2:
Mailing Address - City:PISMO BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:93449-3403
Mailing Address - Country:US
Mailing Address - Phone:805-474-2600
Mailing Address - Fax:805-489-2206
Practice Address - Street 1:931 OAK PARK BLVD STE 101
Practice Address - Street 2:
Practice Address - City:PISMO BEACH
Practice Address - State:CA
Practice Address - Zip Code:93449-3403
Practice Address - Country:US
Practice Address - Phone:805-474-2600
Practice Address - Fax:805-474-2607
Is Sole Proprietor?:No
Enumeration Date:2006-07-02
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA91250207Q00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
7937812OtherAETNA
CA00A912500OtherBLUE SHIELD OF CA PIN
9446736OtherPHCS
12448245OtherMULTIPLAN
CAA91250OtherBLUE CROSS
CAWA91250AMedicare PIN
9446736OtherPHCS