Provider Demographics
NPI:1437296290
Name:MADONNA C MALLARI MD PLLC
Entity Type:Organization
Organization Name:MADONNA C MALLARI MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER PROPRIETER
Authorized Official - Prefix:
Authorized Official - First Name:MADONNA
Authorized Official - Middle Name:C
Authorized Official - Last Name:MALLARI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:480-945-8360
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
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-31
Last Update Date:2007-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ33207207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ883860Medicaid