Provider Demographics
NPI:1982608451
Name:MALLEY, JOHN E (DPM)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:E
Last Name:MALLEY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2664 SW IMMANUEL DR.
Mailing Address - Street 2:
Mailing Address - City:PALM CITY
Mailing Address - State:FL
Mailing Address - Zip Code:34990-2738
Mailing Address - Country:US
Mailing Address - Phone:772-288-3338
Mailing Address - Fax:772-288-3341
Practice Address - Street 1:2664 SW IMMANUEL DR.
Practice Address - Street 2:
Practice Address - City:PALM CITY
Practice Address - State:FL
Practice Address - Zip Code:34990-2738
Practice Address - Country:US
Practice Address - Phone:772-288-3338
Practice Address - Fax:772-288-3341
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-13
Last Update Date:2007-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPO1806213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL87971OtherBCBS ID
FL87971Medicare ID - Type Unspecified
FL5907190001Medicare NSC
FL87971OtherBCBS ID