Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 204C00000X | Sports Medicine Doctor | 19459 | OR |
NPI | 1073858213 |
---|---|
Provider Name | Mr. Joseph F Mallari |
First Address | Beaverton, OR 97007-6365 |
Second Address | Beaverton, OR 97007-6365 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 28/11/2012 |
Last Update Date | 28/11/2012 |