Provider Demographics
NPI:1902893134
Name:MALICKEL, JAY V (DO)
Entity Type:Individual
Prefix:
First Name:JAY
Middle Name:V
Last Name:MALICKEL
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:PO BOX 2284
Mailing Address - Street 2:
Mailing Address - City:VINELAND
Mailing Address - State:NJ
Mailing Address - Zip Code:08362-2284
Mailing Address - Country:US
Mailing Address - Phone:856-358-6161
Mailing Address - Fax:
Practice Address - Street 1:798 CENTERTON RD
Practice Address - Street 2:
Practice Address - City:ELMER
Practice Address - State:NJ
Practice Address - Zip Code:08318-3945
Practice Address - Country:US
Practice Address - Phone:856-358-6161
Practice Address - Fax:856-358-0142
Is Sole Proprietor?:No
Enumeration Date:2005-10-03
Last Update Date:2012-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMB06869400207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
085366400OtherAMERIHEALTH
2325972OtherAETNA/HMO
60009045OtherNJ HEALTH
7591121OtherAETNA PIN
223772973OtherTAX ID
NJ8223904Medicaid
223772973OtherTAX ID
NJH12435Medicare UPIN