Provider Demographics
NPI:1811998230
Name:MALLIS, GARY CRAIG (MD)
Entity type:Individual
Prefix:DR
First Name:GARY
Middle Name:CRAIG
Last Name:MALLIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:20201 N SCOTTSDALE HEALTHCARE DR
Mailing Address - Street 2:SUITE 270
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85255-4134
Mailing Address - Country:US
Mailing Address - Phone:480-585-5355
Mailing Address - Fax:480-585-5358
Practice Address - Street 1:20201 N SCOTTSDALE HEALTHCARE DR
Practice Address - Street 2:SUITE 270
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85255-4134
Practice Address - Country:US
Practice Address - Phone:480-585-5355
Practice Address - Fax:480-585-5358
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
AZ22226208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZF55196Medicare UPIN
AZ65485Medicare ID - Type Unspecified