Provider Demographics
NPI:1457612269
Name:MALO, JUAN SEBASTIAN (MD)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:SEBASTIAN
Last Name:MALO
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:831 RIDGEWOOD DR
Mailing Address - Street 2:
Mailing Address - City:QUINCY
Mailing Address - State:IL
Mailing Address - Zip Code:62301-5773
Mailing Address - Country:US
Mailing Address - Phone:305-205-2288
Mailing Address - Fax:
Practice Address - Street 1:111 E 210TH ST
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10467-2401
Practice Address - Country:US
Practice Address - Phone:718-904-3505
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-07
Last Update Date:2022-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program