Provider Demographics
NPI:1821055278
Name:MALLARE, JOHANNA T (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHANNA
Middle Name:T
Last Name:MALLARE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:108 W TYLER AVE
Mailing Address - Street 2:
Mailing Address - City:WEST MEMPHIS
Mailing Address - State:AR
Mailing Address - Zip Code:72301-4221
Mailing Address - Country:US
Mailing Address - Phone:870-732-1191
Mailing Address - Fax:870-732-4091
Practice Address - Street 1:108 W TYLER AVE
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301-4221
Practice Address - Country:US
Practice Address - Phone:870-732-1191
Practice Address - Fax:870-732-4091
Is Sole Proprietor?:No
Enumeration Date:2006-04-28
Last Update Date:2020-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE2442208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR142052001Medicaid
AR142052001Medicaid
AR142052001Medicaid