Provider Demographics
NPI:1902130891
Name:NALLARI, MITHUN S (MD)
Entity Type:Individual
Prefix:DR
First Name:MITHUN
Middle Name:S
Last Name:NALLARI
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:P.O. BOX 760
Mailing Address - Street 2:
Mailing Address - City:WINCHESTER
Mailing Address - State:MA
Mailing Address - Zip Code:01890-4260
Mailing Address - Country:US
Mailing Address - Phone:781-756-7273
Mailing Address - Fax:781-721-0725
Practice Address - Street 1:23 WARREN AVENUE
Practice Address - Street 2:SUITE #100
Practice Address - City:WOBURN
Practice Address - State:MA
Practice Address - Zip Code:01801-4979
Practice Address - Country:US
Practice Address - Phone:781-933-1198
Practice Address - Fax:781-933-9246
Is Sole Proprietor?:No
Enumeration Date:2009-09-24
Last Update Date:2011-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA241559207R00000X
MA243569207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine