Provider Demographics
NPI:1659458958
Name:MALLOY, DONNA MARIE (OD)
Entity Type:Individual
Prefix:DR
First Name:DONNA
Middle Name:MARIE
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:PO BOX 2089444
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75320-5804
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:732-657-1402
Practice Address - Street 1:1021 ROUTE 70
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:NJ
Practice Address - Zip Code:08759-5804
Practice Address - Country:US
Practice Address - Phone:732-657-1400
Practice Address - Fax:732-657-1402
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2023-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJNJ 5293152W00000X
NJ27OA00529300152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6239404Medicaid
NJ410030895Medicare PIN
423009Medicare PIN
NJU51337Medicare UPIN