Provider Demographics
NPI:1942498852
Name:MALLEN, MATTHEW JAMES (DC)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:JAMES
Last Name:MALLEN
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1214 BENNINGTON ST
Mailing Address - Street 2:
Mailing Address - City:EAST BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02128-1203
Mailing Address - Country:US
Mailing Address - Phone:617-569-6607
Mailing Address - Fax:617-569-8302
Practice Address - Street 1:1214 BENNINGTON ST
Practice Address - Street 2:
Practice Address - City:EAST BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02128-1203
Practice Address - Country:US
Practice Address - Phone:617-569-6607
Practice Address - Fax:617-569-8302
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-05
Last Update Date:2008-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA681111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA351011OtherHARVARDPILGRIM HEALTHCARE
7909287001OtherCIGNA
MAY35466OtherBC/BS OF MA
714763OtherTUFTS HEALTH PLAN
076391OtherAETNA
MA1601776Medicaid
7909287001OtherCIGNA