Provider Demographics
NPI:1295900843
Name:MALONE, CAROLYN MARIE (MD)
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:MARIE
Last Name:MALONE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:MARIE
Other - Last Name:WASSONG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:130 KINDERKAMACK RD STE 200
Mailing Address - Street 2:
Mailing Address - City:RIVER EDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07661-1951
Mailing Address - Country:US
Mailing Address - Phone:201-488-2660
Mailing Address - Fax:
Practice Address - Street 1:30 PROSPECT AVE
Practice Address - Street 2:RADIOLOGY DEPT
Practice Address - City:HACKENSACK
Practice Address - State:NJ
Practice Address - Zip Code:07601-1914
Practice Address - Country:US
Practice Address - Phone:000-000-0000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-24
Last Update Date:2020-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA094321002085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0414841Medicaid
NJ354587TE0Medicare PIN
NJ0414841Medicaid