Provider Demographics
NPI:1548385156
Name:MALLAMO, PAUL (DPM)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:
Last Name:MALLAMO
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:52526 FORD LN
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48047-3514
Mailing Address - Country:US
Mailing Address - Phone:586-598-0455
Mailing Address - Fax:
Practice Address - Street 1:52526 FORD LN
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MI
Practice Address - Zip Code:48047-3514
Practice Address - Country:US
Practice Address - Phone:586-598-0455
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-20
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901001813213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4253362Medicaid
MI480030776OtherRAILROAD MEDICARE
MI4330100001Medicare NSC
MI480030776OtherRAILROAD MEDICARE
MI4253362Medicaid