Provider Demographics
NPI:1871628800
Name:MALLIS, LAURIE R (MD)
Entity type:Individual
Prefix:DR
First Name:LAURIE
Middle Name:R
Last Name:MALLIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 DEVON FARMS RD
Mailing Address - Street 2:
Mailing Address - City:STORMVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:12582-5269
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:845-227-2756
Practice Address - Street 1:801 CO OP CITY BLVD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10475-1603
Practice Address - Country:US
Practice Address - Phone:718-239-6500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-22
Last Update Date:2008-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY166488-1207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY118AE1Medicaid
NY118AE1Medicaid
NY335470Medicare ID - Type Unspecified