Provider Demographics
NPI:1568771210
Name:SEYMOUR MALLIS, M.D., P.C.
Entity Type:Organization
Organization Name:SEYMOUR MALLIS, M.D., P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:SEYMOUR
Authorized Official - Middle Name:
Authorized Official - Last Name:MALLIS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-668-1515
Mailing Address - Street 1:7339 EL CAJON BLVD
Mailing Address - Street 2:SUITE H
Mailing Address - City:LA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:91942-7435
Mailing Address - Country:US
Mailing Address - Phone:619-668-1515
Mailing Address - Fax:619-668-1525
Practice Address - Street 1:7339 EL CAJON BLVD
Practice Address - Street 2:SUITE H
Practice Address - City:LA MESA
Practice Address - State:CA
Practice Address - Zip Code:91942-7435
Practice Address - Country:US
Practice Address - Phone:619-668-1515
Practice Address - Fax:619-668-1525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-29
Last Update Date:2010-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA23608207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA23614Medicare UPIN