Provider Demographics
NPI:1104104025
Name:GENEROSO, ARVI MALLARI (MD)
Entity type:Individual
Prefix:
First Name:ARVI
Middle Name:MALLARI
Last Name:GENEROSO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ARVI
Other - Middle Name:PASTORAL
Other - Last Name:MALLARI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 1163
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:WA
Mailing Address - Zip Code:98611-1163
Mailing Address - Country:US
Mailing Address - Phone:360-800-9480
Mailing Address - Fax:360-800-9486
Practice Address - Street 1:23 COWLITZ W ST
Practice Address - Street 2:
Practice Address - City:CASTL ROCK
Practice Address - State:WA
Practice Address - Zip Code:98611
Practice Address - Country:US
Practice Address - Phone:360-800-9480
Practice Address - Fax:360-800-9486
Is Sole Proprietor?:No
Enumeration Date:2011-07-26
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD60441564207R00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine