Provider Demographics
NPI:1811992050
Name:MALLIS, MARC JEFFREY (MD)
Entity type:Individual
Prefix:DR
First Name:MARC
Middle Name:JEFFREY
Last Name:MALLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:2975 ROLLING WOODS DR
Mailing Address - Street 2:
Mailing Address - City:PALM HARBOR
Mailing Address - State:FL
Mailing Address - Zip Code:34683-2131
Mailing Address - Country:US
Mailing Address - Phone:727-784-8060
Mailing Address - Fax:
Practice Address - Street 1:5347 MAIN ST
Practice Address - Street 2:STE 102
Practice Address - City:NEW PORT RICHEY
Practice Address - State:FL
Practice Address - Zip Code:34652-2506
Practice Address - Country:US
Practice Address - Phone:727-845-1343
Practice Address - Fax:727-845-1343
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2009-02-24
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME 0037030207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL054865101Medicaid
GA180041256Medicare PIN
FL79551QMedicare PIN
FLD58840Medicare UPIN
FL054865101Medicaid
FL79551DMedicare PIN
FL79551EMedicare PIN
FL79551AMedicare PIN