Provider Demographics
NPI:1164985917
Name:WEST, MALLARY (DO)
Entity Type:Individual
Prefix:
First Name:MALLARY
Middle Name:
Last Name:WEST
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6517 DREW AVE S
Mailing Address - Street 2:
Mailing Address - City:EDINA
Mailing Address - State:MN
Mailing Address - Zip Code:55435-2103
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6517 DREW AVE S
Practice Address - Street 2:
Practice Address - City:EDINA
Practice Address - State:MN
Practice Address - Zip Code:55435-2103
Practice Address - Country:US
Practice Address - Phone:952-920-9191
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-09
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MN71840208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program