Provider Demographics
NPI:1366476475
Name:MALLIS, GEORGE ISAAC (MD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:ISAAC
Last Name:MALLIS
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 1:4 TARGET ROCK RD
Mailing Address - Street 2:
Mailing Address - City:LLOYD HARBOR
Mailing Address - State:NY
Mailing Address - Zip Code:11743-9752
Mailing Address - Country:US
Mailing Address - Phone:631-549-9207
Mailing Address - Fax:
Practice Address - Street 1:79 MIDDLEVILLE RD
Practice Address - Street 2:
Practice Address - City:NORTHPORT
Practice Address - State:NY
Practice Address - Zip Code:11768-2200
Practice Address - Country:US
Practice Address - Phone:631-266-6047
Practice Address - Fax:631-754-7968
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY97266207R00000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine