Provider Demographics
NPI:1548452865
Name:MAILLOUX, JOHANNA VALERIE-ELISABETH (MD)
Entity type:Individual
Prefix:
First Name:JOHANNA
Middle Name:VALERIE-ELISABETH
Last Name:MAILLOUX
Suffix:
Gender:F
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:PO BOX 6260 230 MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:HOLYOKE
Mailing Address - State:MA
Mailing Address - Zip Code:01041-6260
Mailing Address - Country:US
Mailing Address - Phone:413-420-2119
Mailing Address - Fax:
Practice Address - Street 1:230 MAPLE ST
Practice Address - Street 2:
Practice Address - City:HOLYOKE
Practice Address - State:MA
Practice Address - Zip Code:01040-5144
Practice Address - Country:US
Practice Address - Phone:413-420-2119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-08-10
Last Update Date:2009-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA239094208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics