Provider Demographics
NPI:1326539826
Name:PHILLIPS, MALLORI (OD)
Entity Type:Individual
Prefix:
First Name:MALLORI
Middle Name:
Last Name:PHILLIPS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:101 CYCLONE LN
Mailing Address - Street 2:
Mailing Address - City:MADRID
Mailing Address - State:IA
Mailing Address - Zip Code:50156-7610
Mailing Address - Country:US
Mailing Address - Phone:515-293-0708
Mailing Address - Fax:
Practice Address - Street 1:3105 GRAND AVE
Practice Address - Street 2:
Practice Address - City:AMES
Practice Address - State:IA
Practice Address - Zip Code:50010-4604
Practice Address - Country:US
Practice Address - Phone:515-441-8127
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-21
Last Update Date:2018-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA091352152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist