Provider Demographics
NPI:1508834854
Name:MALLARI, JUAN J (MD)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:J
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:PO BOX 1849
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04241-1849
Mailing Address - Country:US
Mailing Address - Phone:207-784-2554
Mailing Address - Fax:207-777-5363
Practice Address - Street 1:1440 MAIN STREET
Practice Address - Street 2:
Practice Address - City:WALTHAM
Practice Address - State:MA
Practice Address - Zip Code:02451
Practice Address - Country:US
Practice Address - Phone:781-891-9300
Practice Address - Fax:781-891-9305
Is Sole Proprietor?:No
Enumeration Date:2006-03-12
Last Update Date:2009-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT037082207L00000X
MA78874207L00000X
NJ25MA08043200207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001370824Medicaid
MA3175987Medicaid
MA3175987Medicaid
CT001370824Medicaid