Provider Demographics
NPI:1902002488
Name:MALLARE, LILY ANN (MD)
Entity Type:Individual
Prefix:DR
First Name:LILY
Middle Name:ANN
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 1:3400 DATA DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CORDOVA
Mailing Address - State:CA
Mailing Address - Zip Code:95670-7956
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1700 N ROSE AVE STE 280
Practice Address - Street 2:
Practice Address - City:OXNARD
Practice Address - State:CA
Practice Address - Zip Code:93030-7645
Practice Address - Country:US
Practice Address - Phone:805-384-8071
Practice Address - Fax:805-278-6477
Is Sole Proprietor?:No
Enumeration Date:2007-06-22
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA99023207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1831365667Medicaid
CA1902002488Medicaid
CAZZZ55168YOtherBS/TRIWEST
CA1033399415Medicaid
CAA99023OtherMEDICAL LICENSE
CAZZZ50355YOtherBS/TRIWEST
CA1902002488Medicaid
CABK515ZMedicare PIN
CABG850Medicare PIN
CAA99023OtherMEDICAL LICENSE