Provider Demographics
NPI:1598773384
Name:MALLOY, KELLY A (OD)
Entity Type:Individual
Prefix:DR
First Name:KELLY
Middle Name:A
Last Name:MALLOY
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 E MAPLE AVE
Mailing Address - Street 2:
Mailing Address - City:BELLMAWR
Mailing Address - State:NJ
Mailing Address - Zip Code:08031-1250
Mailing Address - Country:US
Mailing Address - Phone:609-933-3832
Mailing Address - Fax:
Practice Address - Street 1:1200 W GODFREY AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19141-3323
Practice Address - Country:US
Practice Address - Phone:215-276-6000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-04
Last Update Date:2012-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000087152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA1547286OtherBLUE SHIELD
PA026218Medicare ID - Type Unspecified
PA1547286OtherBLUE SHIELD