Provider Demographics
NPI:1720154578
Name:MALY, BETTY JOAN (MD)
Entity Type:Individual
Prefix:DR
First Name:BETTY JOAN
Middle Name:
Last Name:MALY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4282 GENESEE AVE
Mailing Address - Street 2:STE 302
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92117-4946
Mailing Address - Country:US
Mailing Address - Phone:858-450-1122
Mailing Address - Fax:858-571-3649
Practice Address - Street 1:4282 GENESEE AVE
Practice Address - Street 2:STE 302
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92117-4946
Practice Address - Country:US
Practice Address - Phone:858-450-1122
Practice Address - Fax:858-571-3649
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG55531208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAE58427Medicare UPIN