MEDICARE: DR. MARC JEFFREY MALLIS MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician	ME 0037030	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1811992050
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. MARC JEFFREY MALLIS MD

Provider Business Mailing Address
First Line	:	2975 ROLLING WOODS DR
Second Line	:
City	:	PALM HARBOR
State	:	FL
Zip	:	34683-2131
Country	:	US
Telephone Number	:	727-784-8060
Fax Number	:

Provider Business Practice Location Address
First Line	:	5347 MAIN ST
Second Line	:	STE 102
City	:	NEW PORT RICHEY
State	:	FL
Zip	:	34652-2506
Country	:	US
Telephone Number	:	727-845-1343
Fax Number	:	727-845-1343

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/15/2005
Last Update Date	:	02/24/2009

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