Provider Demographics
NPI:1275551350
Name:MALLORY, LEAH A (MD)
Entity Type:Individual
Prefix:
First Name:LEAH
Middle Name:A
Last Name:MALLORY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LEAH
Other - Middle Name:BARTSCH
Other - Last Name:MALLORY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:22 BRAMHALL ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-3134
Mailing Address - Country:US
Mailing Address - Phone:207-662-2541
Mailing Address - Fax:207-662-3172
Practice Address - Street 1:22 BRAMHALL ST
Practice Address - Street 2:DEPT. OF PEDIATRICS
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3134
Practice Address - Country:US
Practice Address - Phone:207-662-2541
Practice Address - Fax:207-662-3172
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2013-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA226905208000000X
MEMD17508208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME003011101Medicare PIN