Provider Demographics
NPI:1992097612
Name:MALOUF, JOHN DAVID (DO)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:DAVID
Last Name:MALOUF
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2855 N 920 E
Mailing Address - Street 2:
Mailing Address - City:NORTH LOGAN
Mailing Address - State:UT
Mailing Address - Zip Code:84341-5806
Mailing Address - Country:US
Mailing Address - Phone:435-557-0354
Mailing Address - Fax:
Practice Address - Street 1:1219 N 400 E
Practice Address - Street 2:
Practice Address - City:LOGAN
Practice Address - State:UT
Practice Address - Zip Code:84341-2321
Practice Address - Country:US
Practice Address - Phone:435-565-6043
Practice Address - Fax:435-220-2030
Is Sole Proprietor?:No
Enumeration Date:2011-05-12
Last Update Date:2021-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5101018972207Q00000X
UT317131-1204207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1992097612Medicaid