Provider Demographics
NPI:1760475750
Name:MALKIN, KENNETH FRED (DPM)
Entity Type:Individual
Prefix:
First Name:KENNETH
Middle Name:FRED
Last Name:MALKIN
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 1:376 BLOOMFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:CALDWELL
Mailing Address - State:NJ
Mailing Address - Zip Code:07006-4905
Mailing Address - Country:US
Mailing Address - Phone:973-226-2263
Mailing Address - Fax:973-228-2013
Practice Address - Street 1:376 BLOOMFIELD AVE
Practice Address - Street 2:
Practice Address - City:CALDWELL
Practice Address - State:NJ
Practice Address - Zip Code:07006-4905
Practice Address - Country:US
Practice Address - Phone:973-226-2263
Practice Address - Fax:973-228-2013
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MD00155800213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0823740001OtherDMERC
NJ2101009Medicaid
NJMA456488Medicare ID - Type Unspecified
NJT45532Medicare UPIN