Provider Demographics
NPI:1659317873
Name:MALLETT, JOHN H (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:H
Last Name:MALLETT
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 1:147 REYNOIR ST
Mailing Address - Street 2:STE 105
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39530
Mailing Address - Country:US
Mailing Address - Phone:228-436-6658
Mailing Address - Fax:228-432-9455
Practice Address - Street 1:147 REYNOIR ST
Practice Address - Street 2:STE 105
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39530
Practice Address - Country:US
Practice Address - Phone:228-436-6658
Practice Address - Fax:228-432-9455
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS11052207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00115234Medicaid
C68915Medicare UPIN