Provider Demographics
NPI:1316622541
Name:DEFAY, MALINO RIEL JAVIER (OD)
Entity type:Individual
Prefix:
First Name:MALINO
Middle Name:RIEL JAVIER
Last Name:DEFAY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:283 CEDAR HEIGHTS DR
Mailing Address - Street 2:
Mailing Address - City:DUNCANSVILLE
Mailing Address - State:PA
Mailing Address - Zip Code:16635-4627
Mailing Address - Country:US
Mailing Address - Phone:814-215-0811
Mailing Address - Fax:
Practice Address - Street 1:6231 N CHARLES ST # 1
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21212-1113
Practice Address - Country:US
Practice Address - Phone:410-337-2044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-06-15
Last Update Date:2023-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDTA2914152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist