Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 208000000X | Pediatrician | 2013021354 | MO |
Y | 2080P0203X | Pediatric Critical Care Doctor | 2013021354 | MO |
NPI | 1093940751 |
---|---|
Provider Name | Dr. Jay Randolph Malone |
First Address | Saint Louis, MO 63110-1002 |
Second Address | Saint Louis, MO 63110-1002 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 26/05/2009 |
Last Update Date | 15/11/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
200032754 | (05) | MO |