Provider Demographics
NPI:1376563643
Name:MALLIE, AARON RICHARD (OD)
Entity Type:Individual
Prefix:DR
First Name:AARON
Middle Name:RICHARD
Last Name:MALLIE
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 1:6677 COUNTRY WINDS CV
Mailing Address - Street 2:
Mailing Address - City:LAKE WORTH
Mailing Address - State:FL
Mailing Address - Zip Code:33463-7433
Mailing Address - Country:US
Mailing Address - Phone:954-873-7624
Mailing Address - Fax:
Practice Address - Street 1:701 N CONGRESS AVE
Practice Address - Street 2:#2
Practice Address - City:BOYNTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:33426-3471
Practice Address - Country:US
Practice Address - Phone:561-732-5667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-20
Last Update Date:2011-02-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 3916152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist