Provider Demographics
NPI:1619067261
Name:MALLOY, WALTER N (MD)
Entity Type:Individual
Prefix:DR
First Name:WALTER
Middle Name:N
Last Name:MALLOY
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 1407
Mailing Address - Street 2:
Mailing Address - City:TAPPAHANNOCK
Mailing Address - State:VA
Mailing Address - Zip Code:22560-1407
Mailing Address - Country:US
Mailing Address - Phone:804-370-4093
Mailing Address - Fax:804-443-0439
Practice Address - Street 1:1101 JOHNSON AVE
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29577-1893
Practice Address - Country:US
Practice Address - Phone:843-477-0177
Practice Address - Fax:843-518-4022
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2019-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101027084207RI0011X, 207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207RI0011XAllopathic & Osteopathic PhysiciansInternal MedicineInterventional Cardiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6075886Medicaid
060000492Medicare ID - Type Unspecified
B09579Medicare UPIN