Provider Demographics
NPI:1861544561
Name:MALONE, T L (OD)
Entity type:Individual
Prefix:
First Name:T
Middle Name:L
Last Name:MALONE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:401 EAST A STREET
Mailing Address - Street 2:
Mailing Address - City:OGALLALA
Mailing Address - State:NE
Mailing Address - Zip Code:69153-2123
Mailing Address - Country:US
Mailing Address - Phone:308-284-4194
Mailing Address - Fax:
Practice Address - Street 1:401 EAST A STREET
Practice Address - Street 2:
Practice Address - City:OGALLALA
Practice Address - State:NE
Practice Address - Zip Code:69153-2123
Practice Address - Country:US
Practice Address - Phone:308-284-4194
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE684152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE06871OtherBC/BS OF NE.
NE47045806700Medicaid
NE06871OtherBC/BS OF NE.
NET80128Medicare UPIN
NE0511480001Medicare NSC