Provider Demographics
NPI:1235146846
Name:MALLARD, GREGORY WAYNE (MD)
Entity Type:Individual
Prefix:
First Name:GREGORY
Middle Name:WAYNE
Last Name:MALLARD
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 1:140 STONERIDGE DR S STE 100
Mailing Address - Street 2:
Mailing Address - City:RUCKERSVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22968-3096
Mailing Address - Country:US
Mailing Address - Phone:434-654-1850
Mailing Address - Fax:
Practice Address - Street 1:425 W JACKSON ST
Practice Address - Street 2:
Practice Address - City:PIGGOTT
Practice Address - State:AR
Practice Address - Zip Code:72454-1538
Practice Address - Country:US
Practice Address - Phone:870-598-2236
Practice Address - Fax:870-598-3080
Is Sole Proprietor?:No
Enumeration Date:2006-08-03
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARE2399207Q00000X
VA0101265974207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR140508001Medicaid
AR140508001Medicaid
ARH13948Medicare UPIN
AR140508001Medicaid