Provider Demographics
NPI:1982689147
Name:MALLARI, JESUS VELASQUEZ (MD)
Entity Type:Individual
Prefix:DR
First Name:JESUS
Middle Name:VELASQUEZ
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 1:3551 ROGER BROOKE DR
Mailing Address - Street 2:
Mailing Address - City:FORT SAM HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:78234-4504
Mailing Address - Country:US
Mailing Address - Phone:210-539-9582
Mailing Address - Fax:
Practice Address - Street 1:5483 PAPAGALLO DR
Practice Address - Street 2:
Practice Address - City:OCEANSIDE
Practice Address - State:CA
Practice Address - Zip Code:92057-1907
Practice Address - Country:US
Practice Address - Phone:760-231-1611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-09
Last Update Date:2021-01-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FM4301047321208000000X
MI4301047321208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics