Provider Demographics
NPI:1922186246
Name:MALLOY, CHRISTOPHER BRIEN (OD)
Entity Type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:BRIEN
Last Name:MALLOY
Suffix:
Gender:M
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:75320-6010
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:636-527-0766
Practice Address - Street 1:359 BRICK BLVD
Practice Address - Street 2:
Practice Address - City:BRICK
Practice Address - State:NJ
Practice Address - Zip Code:08723-6010
Practice Address - Country:US
Practice Address - Phone:732-920-1330
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-02
Last Update Date:2022-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ5294152W00000X
NJ27OA00529400152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ6247105Medicaid
NJU54753Medicare UPIN
NJ6247105Medicaid