Provider Demographics
NPI:1477567642
Name:MALLIS, MICHAEL J (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:J
Last Name:MALLIS
Suffix:
Gender:M
Credentials:DO
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Mailing Address - Street 1:2900 CORPORATE WAY
Mailing Address - Street 2:DOOR D
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33025-3925
Mailing Address - Country:US
Mailing Address - Phone:954-276-5685
Mailing Address - Fax:954-985-7074
Practice Address - Street 1:4651 SHERIDAN ST STE 350
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-3425
Practice Address - Country:US
Practice Address - Phone:954-276-8559
Practice Address - Fax:954-966-9762
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2021-03-17
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
FLOS8804208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL274719700Medicaid
FL288179OtherAVMED
FL274719700Medicaid
FL288179OtherAVMED
FL62696XMedicare PIN