Provider Demographics
NPI:1316916901
Name:MALLOY, DENNIS (MD)
Entity type:Individual
Prefix:
First Name:DENNIS
Middle Name:
Last Name:MALLOY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:44405 WOODWARD AVE
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48341-5023
Mailing Address - Country:US
Mailing Address - Phone:248-858-3126
Mailing Address - Fax:248-858-6499
Practice Address - Street 1:44405 WOODWARD AVE
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-5023
Practice Address - Country:US
Practice Address - Phone:248-858-3126
Practice Address - Fax:248-858-6499
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2010-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301052200207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2788295Medicaid
MIOMO2170059Medicare ID - Type Unspecified
MIF37573Medicare UPIN