Provider Demographics
NPI:1588699490
Name:MALLO, RICHARD (MD)
Entity type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:MALLO
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 1:225 EAST SECOND AVENUE
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92025-4249
Mailing Address - Country:US
Mailing Address - Phone:760-291-6700
Mailing Address - Fax:760-737-7324
Practice Address - Street 1:225 E 2ND AVE
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92025-4249
Practice Address - Country:US
Practice Address - Phone:760-291-6700
Practice Address - Fax:760-737-7324
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2024-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA70324207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA110231959OtherMEDICARE RR
CAG54018Medicare UPIN
CA110231959OtherMEDICARE RR