Provider Demographics
NPI:1093248379
Name:DACUS, MALLORY ROBERTS (MD)
Entity Type:Individual
Prefix:DR
First Name:MALLORY
Middle Name:ROBERTS
Last Name:DACUS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MALLORY
Other - Middle Name:
Other - Last Name:ROBERTS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:847 MONROE AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38103-4901
Mailing Address - Country:US
Mailing Address - Phone:901-448-6375
Mailing Address - Fax:
Practice Address - Street 1:920 MADISON AVE
Practice Address - Street 2:SUITE 447
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38103
Practice Address - Country:US
Practice Address - Phone:901-516-8529
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-04-04
Last Update Date:2018-07-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program