Basic Information
| Provider Information | |||||||||
| NPI: | 1992773287 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MALONE | ||||||||
| FirstName: | JOHN | ||||||||
| MiddleName: | GREEN | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 602658 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282602658 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367162011 | ||||||||
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| Practice Location | |||||||||
| Address1: | 500 SHEPHERD ST | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271031633 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367164101 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2006 | ||||||||
| LastUpdateDate: | 01/15/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 9400568 | NC | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 54933 | 01 | NC | BLUE CROSS BLUE SHIELD | OTHER | 11618 | 01 | NC | PARTNERS MEDICARE | OTHER | 8954933 | 05 | NC | MEDICAID |