Provider Demographics
NPI:1255336129
Name:MALOTTE, MICHAEL J
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:J
Last Name:MALOTTE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:895 AEROVISTA PL
Mailing Address - Street 2:103
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-8724
Mailing Address - Country:US
Mailing Address - Phone:805-541-2368
Mailing Address - Fax:
Practice Address - Street 1:895 AEROVISTA PL
Practice Address - Street 2:103
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-8724
Practice Address - Country:US
Practice Address - Phone:805-541-2368
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2021-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG61212207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG02206Medicare UPIN