Provider Demographics
NPI:1205991965
Name:MALLARI, RAYMUNDO T (MD)
Entity type:Individual
Prefix:
First Name:RAYMUNDO
Middle Name:T
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 1:285 DIX LEEON DR
Mailing Address - Street 2:
Mailing Address - City:FAIRBURN
Mailing Address - State:GA
Mailing Address - Zip Code:30213-3609
Mailing Address - Country:US
Mailing Address - Phone:770-461-5436
Mailing Address - Fax:770-461-5436
Practice Address - Street 1:285 DIX LEEON DR
Practice Address - Street 2:
Practice Address - City:FAIRBURN
Practice Address - State:GA
Practice Address - Zip Code:30213-3609
Practice Address - Country:US
Practice Address - Phone:770-461-5436
Practice Address - Fax:770-461-5436
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA017855174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAD30218Medicare UPIN