Provider Demographics
NPI:1184736043
Name:O'MALLEY, MARK E (DC)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:E
Last Name:O'MALLEY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:78 BEAVER RD
Mailing Address - Street 2:SUITE 2A
Mailing Address - City:WETHERSFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06109-2295
Mailing Address - Country:US
Mailing Address - Phone:860-257-9400
Mailing Address - Fax:860-257-7169
Practice Address - Street 1:78 BEAVER RD
Practice Address - Street 2:SUITE 2A
Practice Address - City:WETHERSFIELD
Practice Address - State:CT
Practice Address - Zip Code:06109-2295
Practice Address - Country:US
Practice Address - Phone:860-257-9400
Practice Address - Fax:860-257-7169
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2010-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTCT000731111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT682637OtherCONNECTICARE
CT2V2010OtherHEALTHNET
CT050000731CT01OtherANTHEM BLUE CROSS
CT519710OtherAETNA
CT4590708OtherENVOY/AETNA
CT519710OtherAETNA
CT519710OtherAETNA
CTT92884Medicare UPIN