Basic Information
| Provider Information | |||||||||
| NPI: | 1083646798 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MALLOY | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | ROBERT | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1589 PRINDLE RD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054459180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8024255442 | ||||||||
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| Practice Location | |||||||||
| Address1: | 300 FLYNN AVE | ||||||||
| Address2: | |||||||||
| City: | BURLINGTON | ||||||||
| State: | VT | ||||||||
| PostalCode: | 054015301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8026580400 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 08/21/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | 042-0008866 | VT | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 0VN0340 | 05 | VT | MEDICAID |