Provider Demographics
NPI:1043235377
Name:MALLEA, MICHAEL CRAIG (MD)
Entity type:Individual
Prefix:
First Name:MICHAEL
Middle Name:CRAIG
Last Name:MALLEA
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3355 RIVERBEND DR
Mailing Address - Street 2:STE 200
Mailing Address - City:SPRINGFIELD
Mailing Address - State:OR
Mailing Address - Zip Code:97477-8800
Mailing Address - Country:US
Mailing Address - Phone:541-868-9247
Mailing Address - Fax:541-485-0452
Practice Address - Street 1:3355 RIVERBEND DR STE 200
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:OR
Practice Address - Zip Code:97477-8800
Practice Address - Country:US
Practice Address - Phone:541-868-9247
Practice Address - Fax:541-485-0452
Is Sole Proprietor?:No
Enumeration Date:2006-07-13
Last Update Date:2022-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7108174400000X, 207RN0300X
ORMD20251207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID12252OtherBLUE CROSS
OR150023Medicaid
ID390004362OtherRR MEDICARE
ID000010002160OtherBLUE SHIELD
ID003813700Medicaid
ID003813700Medicaid
ID003813700Medicaid
IDA01620Medicare UPIN