Provider Demographics
NPI:1548769912
Name:MALONEY, JUSTIN
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:MALONEY
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 1:2900 DOOLITTLE DR
Mailing Address - Street 2:
Mailing Address - City:ELLSWORTH AFB
Mailing Address - State:SD
Mailing Address - Zip Code:57706-4821
Mailing Address - Country:US
Mailing Address - Phone:056-385-6700
Mailing Address - Fax:
Practice Address - Street 1:2900 DOOLITTLE DR
Practice Address - Street 2:
Practice Address - City:ELLSWORTH AFB
Practice Address - State:SD
Practice Address - Zip Code:57706-4821
Practice Address - Country:US
Practice Address - Phone:056-385-6700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-12
Last Update Date:2023-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN69826207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine