Provider Demographics
NPI:1649284191
Name:MALLONEE, JOHN D JR (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:D
Last Name:MALLONEE
Suffix:JR
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 1:2716 S US HIGHWAY 1
Mailing Address - Street 2:
Mailing Address - City:FORT PIERCE
Mailing Address - State:FL
Mailing Address - Zip Code:34982-5919
Mailing Address - Country:US
Mailing Address - Phone:772-467-0605
Mailing Address - Fax:
Practice Address - Street 1:2716 S US HIGHWAY 1
Practice Address - Street 2:
Practice Address - City:FORT PIERCE
Practice Address - State:FL
Practice Address - Zip Code:34982-5919
Practice Address - Country:US
Practice Address - Phone:772-467-0605
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-28
Last Update Date:2016-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL0021825207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL058484300Medicaid
D86052Medicare UPIN
FL058484300Medicaid