Provider Demographics
NPI:1659341667
Name:MALLACE, ALAN H (MD)
Entity Type:Individual
Prefix:
First Name:ALAN
Middle Name:H
Last Name:MALLACE
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 1:10474 W THUNDERBIRD BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SUN CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:85351-3015
Mailing Address - Country:US
Mailing Address - Phone:866-974-2673
Mailing Address - Fax:866-939-2673
Practice Address - Street 1:18444 N 25TH AVE
Practice Address - Street 2:STE 310
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85023-1266
Practice Address - Country:US
Practice Address - Phone:866-974-2673
Practice Address - Fax:866-939-2673
Is Sole Proprietor?:No
Enumeration Date:2006-01-23
Last Update Date:2014-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ9569174400000X, 207R00000X
AZ09569207RR0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RR0500XAllopathic & Osteopathic PhysiciansInternal MedicineRheumatology
No174400000XOther Service ProvidersSpecialist
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ246042Medicaid
AZ24963Medicare ID - Type Unspecified
AZ24961Medicare ID - Type Unspecified
AZ24962Medicare ID - Type Unspecified
AZ246042Medicaid
AZZ152178Medicare PIN
AZ21439Medicare ID - Type Unspecified
AZC99925Medicare UPIN
AZ24960Medicare ID - Type Unspecified