Provider Demographics
NPI:1881635811
Name:MALLON, WILLIAM KINNEY JR (MD)
Entity type:Individual
Prefix:
First Name:WILLIAM
Middle Name:KINNEY
Last Name:MALLON
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:PO BOX 1554
Mailing Address - Street 2:
Mailing Address - City:STONY BROOK
Mailing Address - State:NY
Mailing Address - Zip Code:11790-0988
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:STONY BROOK MEDICINE DEPT OF EMERGENCY
Practice Address - Street 2:HSC, LEVEL 4, ROOM 080
Practice Address - City:STONY BROOK
Practice Address - State:NY
Practice Address - Zip Code:11794-8350
Practice Address - Country:US
Practice Address - Phone:631-444-2478
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2015-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY282233207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G640550Medicaid
CA00G640550Medicaid
CAWG64055EMedicare ID - Type Unspecified