Provider Demographics
NPI:1588633226
Name:O'MALLEY, CHERYL W (MD)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:W
Last Name:O'MALLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1441 N 12TH ST
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85006-2837
Mailing Address - Country:US
Mailing Address - Phone:602-495-4577
Mailing Address - Fax:602-417-3459
Practice Address - Street 1:1111 E MCDOWELL RD
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85006-2612
Practice Address - Country:US
Practice Address - Phone:602-239-2296
Practice Address - Fax:602-239-2084
Is Sole Proprietor?:No
Enumeration Date:2006-03-15
Last Update Date:2023-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ31349207R00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ76359OtherARIZONA MEDICARE FARGO PART B
AZ76359Medicaid
76359Medicare ID - Type Unspecified
AZ76359Medicaid
838013Medicare ID - Type Unspecified
83102Medicare ID - Type Unspecified