Provider Demographics
NPI:1558333492
Name:MALLO, CHARLES J (MD)
Entity Type:Individual
Prefix:DR
First Name:CHARLES
Middle Name:J
Last Name:MALLO
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:988 OAK RIDGE TPKE
Mailing Address - Street 2:SUITE 350
Mailing Address - City:OAK RIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37830-6930
Mailing Address - Country:US
Mailing Address - Phone:865-483-7030
Mailing Address - Fax:865-483-3954
Practice Address - Street 1:988 OAK RIDGE TPKE
Practice Address - Street 2:SUITE 350
Practice Address - City:OAK RIDGE
Practice Address - State:TN
Practice Address - Zip Code:37830-6930
Practice Address - Country:US
Practice Address - Phone:865-483-7030
Practice Address - Fax:865-483-3954
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-05
Last Update Date:2014-05-29
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NY132331-1174400000X
NY132331208600000X, 2086S0129X
TN491482086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
No174400000XOther Service ProvidersSpecialist
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00593242Medicaid
NYAA0471Medicare PIN
NY00593242Medicaid
NYB71662Medicare UPIN