Provider Demographics
NPI:1083620447
Name:MALLORY, MARSHALL P (MD)
Entity Type:Individual
Prefix:DR
First Name:MARSHALL
Middle Name:P
Last Name:MALLORY
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:PO BOX 320757
Mailing Address - Street 2:
Mailing Address - City:LOS GATOS
Mailing Address - State:CA
Mailing Address - Zip Code:95032-0112
Mailing Address - Country:US
Mailing Address - Phone:888-318-8900
Mailing Address - Fax:408-370-9131
Practice Address - Street 1:20 INDIAN PINE TRCE W
Practice Address - Street 2:
Practice Address - City:GADSDEN
Practice Address - State:AL
Practice Address - Zip Code:35901-7240
Practice Address - Country:US
Practice Address - Phone:888-318-8900
Practice Address - Fax:408-370-9131
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2024-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2441682085R0202X
AL123782085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
F21571Medicare UPIN