1811992050 NPI number — DR. MARC JEFFREY MALLIS MD

Table of content: DR. MARC JEFFREY MALLIS MD (NPI 1811992050)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1811992050 NPI number — DR. MARC JEFFREY MALLIS MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MALLIS
Provider First Name:
MARC
Provider Middle Name:
JEFFREY
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1811992050
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/24/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2975 ROLLING WOODS DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PALM HARBOR
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
34683-2131
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
727-784-8060
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5347 MAIN ST
Provider Second Line Business Practice Location Address:
STE 102
Provider Business Practice Location Address City Name:
NEW PORT RICHEY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
34652-2506
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
727-845-1343
Provider Business Practice Location Address Fax Number:
727-845-1343
Provider Enumeration Date:
06/15/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207W00000X , with the licence number:  ME 0037030 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 054865101 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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