Provider Demographics
NPI:1093725368
Name:MALLORY, DAVID B (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:B
Last Name:MALLORY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:12105 S WENTWORTH PL
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73170-4822
Mailing Address - Country:US
Mailing Address - Phone:405-691-6219
Mailing Address - Fax:
Practice Address - Street 1:1240 SW 44TH ST
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73109-3604
Practice Address - Country:US
Practice Address - Phone:405-631-1527
Practice Address - Fax:405-631-9930
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK10466208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
OKD42609Medicare UPIN