Provider Demographics
NPI:1255569570
Name:MALLON, ANDREW SEAN (DO)
Entity type:Individual
Prefix:DR
First Name:ANDREW
Middle Name:SEAN
Last Name:MALLON
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:2515 COUNTRYSIDE BLVD
Mailing Address - Street 2:SUITE E
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33763-1603
Mailing Address - Country:US
Mailing Address - Phone:727-216-0700
Mailing Address - Fax:727-216-0704
Practice Address - Street 1:1330 S FORT HARRISON AVE
Practice Address - Street 2:
Practice Address - City:CLEARWATER
Practice Address - State:FL
Practice Address - Zip Code:33756-3313
Practice Address - Country:US
Practice Address - Phone:727-216-0700
Practice Address - Fax:727-216-0704
Is Sole Proprietor?:No
Enumeration Date:2009-06-25
Last Update Date:2024-05-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLOS12619207Y00000X
PAOT013216207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL010925000Medicaid
FLOS12619OtherSTATE OF FLORIDA MEDICAL LICENSE