Provider Demographics
NPI:1831173921
Name:MALLATT, BRUCE DOUGLAS (MD)
Entity type:Individual
Prefix:MR
First Name:BRUCE
Middle Name:DOUGLAS
Last Name:MALLATT
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 1:700 WILLOW ST
Mailing Address - Street 2:SUITE 203
Mailing Address - City:VINCENNES
Mailing Address - State:IN
Mailing Address - Zip Code:47591-1028
Mailing Address - Country:US
Mailing Address - Phone:812-886-4572
Mailing Address - Fax:812-886-6571
Practice Address - Street 1:700 WILLOW ST
Practice Address - Street 2:SUITE 203
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-1028
Practice Address - Country:US
Practice Address - Phone:812-886-4572
Practice Address - Fax:812-886-6571
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-01
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01027539207N00000X, 207NS0135X, 207ND0101X, 207ND0900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
No207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100154760AMedicaid
351505869OtherFEDERAL TAX ID NUMBER
IN442810Medicare ID - Type Unspecified
IN100154760AMedicaid