Basic Information
| Provider Information | |||||||||
| NPI: | 1306825609 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MALON | ||||||||
| FirstName: | ANDREA | ||||||||
| MiddleName: | MARIE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 862 ARBUTUS ST | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064575177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8603462608 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 540 SAYBROOK RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064574760 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8603582850 | ||||||||
| FaxNumber: | 8603588698 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2006 | ||||||||
| LastUpdateDate: | 03/03/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/03/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0129X | 033184 | CT | N | Allopathic & Osteopathic Physicians | Surgery | Vascular Surgery | 2086X0206X | 033184 | CT | N | Allopathic & Osteopathic Physicians | Surgery | Surgical Oncology | 208C00000X | 033184 | CT | N | Allopathic & Osteopathic Physicians | Colon & Rectal Surgery | 208600000X | 21347 | CT | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 001331842 | 05 | CT | MEDICAID |