Provider Demographics
NPI:1932524485
Name:LITOS O. MALLARE, M.D., INC.
Entity Type:Organization
Organization Name:LITOS O. MALLARE, M.D., INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PSYCHIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LITOS
Authorized Official - Middle Name:O
Authorized Official - Last Name:MALLARE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:310-650-8951
Mailing Address - Street 1:23823 MALIBU RD
Mailing Address - Street 2:SUITE 50, #189
Mailing Address - City:MALIBU
Mailing Address - State:CA
Mailing Address - Zip Code:90265-4628
Mailing Address - Country:US
Mailing Address - Phone:310-650-8951
Mailing Address - Fax:310-457-1082
Practice Address - Street 1:23823 MALIBU RD
Practice Address - Street 2:SUITE 50, #189
Practice Address - City:MALIBU
Practice Address - State:CA
Practice Address - Zip Code:90265-4628
Practice Address - Country:US
Practice Address - Phone:310-650-8951
Practice Address - Fax:310-457-1082
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LITOS O. MALLARE, M.D., INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-02-20
Last Update Date:2015-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA693172084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A693172Medicaid
CAODA693170Medicaid
CA00A693172Medicaid