Basic Information
| Provider Information | |||||||||
| NPI: | 1992787238 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MALONEY | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | D | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1105 | ||||||||
| Address2: | |||||||||
| City: | YREKA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960971105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5308424121 | ||||||||
| FaxNumber: | 5308429054 | ||||||||
| Practice Location | |||||||||
| Address1: | 444 BRUCE ST | ||||||||
| Address2: | |||||||||
| City: | YREKA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 960973450 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5308424121 | ||||||||
| FaxNumber: | 5308429054 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/14/2005 | ||||||||
| LastUpdateDate: | 01/12/2009 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | G46471 | CA | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | GR0041660 | 05 | CA | MEDICAID |