Basic Information
| Provider Information | |||||||||
| NPI: | 1588663140 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MALLEN | ||||||||
| FirstName: | JONATHAN | ||||||||
| MiddleName: | R | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 165 N VILLAGE AVE | ||||||||
| Address2: | SUITE 128 | ||||||||
| City: | ROCKVILLE CENTRE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115703761 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5165362800 | ||||||||
| FaxNumber: | 5163028182 | ||||||||
| Practice Location | |||||||||
| Address1: | 36 LINCOLN AVE | ||||||||
| Address2: | |||||||||
| City: | ROCKVILLE CENTRE | ||||||||
| State: | NY | ||||||||
| PostalCode: | 115705768 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5165362800 | ||||||||
| FaxNumber: | 5163028182 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2005 | ||||||||
| LastUpdateDate: | 11/13/2013 | ||||||||
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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 | 207XX0005X | 217086 | NY | Y | Allopathic & Osteopathic Physicians | Orthopaedic Surgery | Sports Medicine |
No ID Information.