Provider Demographics
NPI:1336906221
Name:WILLIAM J. MALLON, MD
Entity Type:Organization
Organization Name:WILLIAM J. MALLON, MD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RPHT
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MALCOLM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-299-1404
Mailing Address - Street 1:3500 US HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:VERO BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:32960-4511
Mailing Address - Country:US
Mailing Address - Phone:772-299-1404
Mailing Address - Fax:
Practice Address - Street 1:1707 S 25TH ST
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34947-4709
Practice Address - Country:US
Practice Address - Phone:772-299-1404
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WILLIAM J. MALLON, MD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-03-06
Last Update Date:2024-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332900000XSuppliersNon-Pharmacy Dispensing Site