=====================================================
General NPI Number Information
=====================================================
NPI Number | 1205991965
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RAYMUNDO T MALLARI M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/23/2006
-----------------------------------------------------
Last Update Date | 07/08/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 285 DIX LEEON DR
-----------------------------------------------------
City | FAIRBURN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30213-3609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-461-5436
-----------------------------------------------------
Fax | 770-461-5436
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 285 DIX LEEON DR
-----------------------------------------------------
City | FAIRBURN
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30213-3609
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-461-5436
-----------------------------------------------------
Fax | 770-461-5436
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | 017855
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------