Provider Demographics
NPI:1346537982
Name:MARTINEZ, MALLORY GLYNNIS (MD)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:GLYNNIS
Last Name:MARTINEZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:330 ARKANSAS ST
Mailing Address - Street 2:STE 210
Mailing Address - City:LAWRENCE
Mailing Address - State:KS
Mailing Address - Zip Code:66044-1394
Mailing Address - Country:US
Mailing Address - Phone:785-842-7026
Mailing Address - Fax:
Practice Address - Street 1:330 ARKANSAS ST
Practice Address - Street 2:STE 210
Practice Address - City:LAWRENCE
Practice Address - State:KS
Practice Address - Zip Code:66044-1394
Practice Address - Country:US
Practice Address - Phone:785-842-7026
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-04
Last Update Date:2016-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS9407721207R00000X
KS04-39123207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine