Provider Demographics
NPI:1790002855
Name:O'MALLEY, JOHN THOMAS (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:THOMAS
Last Name:O'MALLEY
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
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Mailing Address - Street 1:221 LONGWOOD AVE
Mailing Address - Street 2:BRIGHAM DERMATOLOGY ASSOCIATES
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02115-5804
Mailing Address - Country:US
Mailing Address - Phone:617-732-4918
Mailing Address - Fax:617-582-6060
Practice Address - Street 1:221 LONGWOOD AVE
Practice Address - Street 2:BRIGHAM DERMATOLOGY ASSOCIATES
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02115-5804
Practice Address - Country:US
Practice Address - Phone:617-732-4918
Practice Address - Fax:617-582-6060
Is Sole Proprietor?:No
Enumeration Date:2010-04-29
Last Update Date:2014-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
IN11015381A390200000X
NY243178207N00000X
MA259346207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program