Provider Demographics
NPI:1669455291
Name:MALLETTE, BRIAN JOSEPH (DPM)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:JOSEPH
Last Name:MALLETTE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 S HARBOR CITY BLVD
Mailing Address - Street 2:SUITE 102
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-1384
Mailing Address - Country:US
Mailing Address - Phone:321-728-0117
Mailing Address - Fax:321-728-0151
Practice Address - Street 1:200 S HARBOR CITY BLVD
Practice Address - Street 2:SUITE 102
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-1384
Practice Address - Country:US
Practice Address - Phone:321-728-0117
Practice Address - Fax:321-728-0151
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-29
Last Update Date:2015-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO2692213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL261086800Medicaid
FL9415057001OtherCIGNA
FL2605728OtherAETNA
FL5532704OtherAETNA
FL480031393OtherRAILROAD MEDICARE
FL65643OtherBLUE CROSS BLUE SHIELD
FL9415057001OtherCIGNA
FL261086800Medicaid