Provider Demographics
NPI:1457351421
Name:MALLARE, LITOS O (MD)
Entity type:Individual
Prefix:
First Name:LITOS
Middle Name:O
Last Name:MALLARE
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 1:23823 MALIBU RD
Mailing Address - Street 2:SUITE 50, #189
Mailing Address - City:MALIBU
Mailing Address - State:CA
Mailing Address - Zip Code:90265-4628
Mailing Address - Country:US
Mailing Address - Phone:310-650-8951
Mailing Address - Fax:310-457-1082
Practice Address - Street 1:23823 MALIBU RD
Practice Address - Street 2:SUITE 50, #189
Practice Address - City:MALIBU
Practice Address - State:CA
Practice Address - Zip Code:90265-4628
Practice Address - Country:US
Practice Address - Phone:310-650-8951
Practice Address - Fax:310-457-1082
Is Sole Proprietor?:No
Enumeration Date:2005-07-29
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA693172084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A693172Medicaid
CAP00032627OtherRAILROAD MEDICARE
CAODA693170Medicaid
CAODA693170Medicaid
CAH59069Medicare UPIN
CAWA69317AMedicare PIN