Provider Demographics
NPI:1588663140
Name:MALLEN, JONATHAN R (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:R
Last Name:MALLEN
Suffix:
Gender:M
Credentials:MD
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Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:165 N VILLAGE AVE
Mailing Address - Street 2:SUITE 128
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-3761
Mailing Address - Country:US
Mailing Address - Phone:516-536-2800
Mailing Address - Fax:516-302-8182
Practice Address - Street 1:36 LINCOLN AVE
Practice Address - Street 2:
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-5768
Practice Address - Country:US
Practice Address - Phone:516-536-2800
Practice Address - Fax:516-302-8182
Is Sole Proprietor?:No
Enumeration Date:2005-07-18
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY217086207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY6894720001Medicare NSC
NYI06242Medicare UPIN
NY583G81Medicare ID - Type Unspecified