Provider Demographics
NPI:1154345585
Name:MALLARI, CLINTON (MD)
Entity type:Individual
Prefix:DR
First Name:CLINTON
Middle Name:
Last Name:MALLARI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 W MAIN ST
Mailing Address - Street 2:SUITE 102
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83702-7302
Mailing Address - Country:US
Mailing Address - Phone:208-342-4700
Mailing Address - Fax:208-342-4710
Practice Address - Street 1:115 W MAIN ST
Practice Address - Street 2:SUITE 102
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83702-7302
Practice Address - Country:US
Practice Address - Phone:208-342-4700
Practice Address - Fax:208-342-4710
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM62872081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDB48394Medicare UPIN
ID1103585Medicare ID - Type UnspecifiedMEDICARE NUMBER