Provider Demographics
NPI:1558336958
Name:MALLOV, JOSEPH S (MD)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:S
Last Name:MALLOV
Suffix:
Gender:M
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:PO BOX 92900
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97292-0900
Mailing Address - Country:US
Mailing Address - Phone:503-255-3404
Mailing Address - Fax:
Practice Address - Street 1:10101 SE MAIN ST
Practice Address - Street 2:SUITE 1001
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97216-2455
Practice Address - Country:US
Practice Address - Phone:503-255-3404
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-02-20
Last Update Date:2013-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN33955207RE0101X
ORMD150628207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
460002986OtherMEDICARE RAILROAD
460002986OtherMEDICARE RAILROAD
TNE03664Medicare UPIN
TN3849743Medicare PIN