Provider Demographics
NPI:1407005168
Name:MALLARI, ALEXANDER OTE (MD)
Entity Type:Individual
Prefix:
First Name:ALEXANDER
Middle Name:OTE
Last Name:MALLARI
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 1:3400 DATA DR
Mailing Address - Street 2:PHYSICIAN SUPPORT SERVICES
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4001 J ST
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95819-3626
Practice Address - Country:US
Practice Address - Phone:916-453-4966
Practice Address - Fax:916-966-3189
Is Sole Proprietor?:No
Enumeration Date:2008-09-17
Last Update Date:2021-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY269830207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01131126/RGHMedicaid
NY03007063/NWKMedicaid
NY03393148Medicaid
NYJ400053861Medicare PIN
NY01131126/RGHMedicaid
NY03393148Medicaid
NYJ400053860Medicare PIN
NY70005A/RGHMedicare PIN