Provider Demographics
NPI:1629268321
Name:MACCONMARA, MALCOLM POL (MB BCH)
Entity Type:Individual
Prefix:DR
First Name:MALCOLM
Middle Name:POL
Last Name:MACCONMARA
Suffix:
Gender:M
Credentials:MB BCH
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 845347
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75284-5347
Mailing Address - Country:US
Mailing Address - Phone:214-645-1919
Mailing Address - Fax:214-645-1918
Practice Address - Street 1:5323 HARRY HINES BLVD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75390-7208
Practice Address - Country:US
Practice Address - Phone:214-645-1919
Practice Address - Fax:214-645-1918
Is Sole Proprietor?:No
Enumeration Date:2007-07-28
Last Update Date:2014-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2007010552208600000X
TXQ0967208600000X, 204F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
No204F00000XAllopathic & Osteopathic PhysiciansTransplant Surgery