Provider Demographics
NPI:1164402285
Name:MALLARI, MADONNA C (MD)
Entity Type:Individual
Prefix:
First Name:MADONNA
Middle Name:C
Last Name:MALLARI
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 1:9953 N 95TH ST
Mailing Address - Street 2:SUITE 105
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85258-4593
Mailing Address - Country:US
Mailing Address - Phone:480-945-8360
Mailing Address - Fax:480-945-4555
Practice Address - Street 1:9953 N 95TH ST
Practice Address - Street 2:SUITE 105
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85258-4593
Practice Address - Country:US
Practice Address - Phone:480-945-8360
Practice Address - Fax:480-945-4555
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-17
Last Update Date:2013-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ33207207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ883860Medicaid
AZ883860Medicaid
83406Medicare ID - Type Unspecified