Healthcare Provider Details

I. General information

NPI: 1053331462
Provider Name (Legal Business Name): MARCOS MALLI DE ESCOBAR N.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/20/2006
Last Update Date: 01/18/2024
Certification Date: 01/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

417 HIGHLAND AVE STE 2
WATERBURY CT
06708-3454
US

IV. Provider business mailing address

10900 N SCOTTSDALE RD
SCOTTSDALE AZ
85254-5216
US

V. Phone/Fax

Practice location:
  • Phone: 203-560-5990
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175F00000X
TaxonomyNaturopath
License Number000352
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number06917
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: