Provider Demographics
NPI:1164446514
Name:MALLORY, PATRICK LAWRENCE (DO)
Entity Type:Individual
Prefix:DR
First Name:PATRICK
Middle Name:LAWRENCE
Last Name:MALLORY
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1548 BOISE AVE
Mailing Address - Street 2:
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-4215
Mailing Address - Country:US
Mailing Address - Phone:970-669-9245
Mailing Address - Fax:970-669-9247
Practice Address - Street 1:1548 N. BOISE AVE
Practice Address - Street 2:
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538-4215
Practice Address - Country:US
Practice Address - Phone:970-669-9245
Practice Address - Fax:970-669-9247
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO40960207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
COI24756Medicare UPIN
CO800889Medicare ID - Type Unspecified