Provider Demographics
NPI:1669787784
Name:MALTE, BRIAN IMBAO (MD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:IMBAO
Last Name:MALTE
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 1:555 W 6TH ST
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:AR
Mailing Address - Zip Code:72653-3409
Mailing Address - Country:US
Mailing Address - Phone:870-425-1787
Mailing Address - Fax:
Practice Address - Street 1:628 HOSPITAL DR STE 3A
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:AR
Practice Address - Zip Code:72653-2952
Practice Address - Country:US
Practice Address - Phone:870-425-1787
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-12
Last Update Date:2021-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MO2012037638207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program