Provider Demographics
NPI:1598840530
Name:MALLER, HAROLD MARTIN (MD)
Entity Type:Individual
Prefix:DR
First Name:HAROLD
Middle Name:MARTIN
Last Name:MALLER
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:3212 N WINDSONG DR STE 200
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86314-2255
Mailing Address - Country:US
Mailing Address - Phone:928-583-1000
Mailing Address - Fax:866-751-4157
Practice Address - Street 1:3212 N WINDSONG DR STE 200
Practice Address - Street 2:
Practice Address - City:PRESCOTT VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86314-2255
Practice Address - Country:US
Practice Address - Phone:928-583-1000
Practice Address - Fax:866-751-4157
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG7742208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA000G77420Medicaid
AZ420636Medicaid