Provider Demographics
NPI:1376258814
Name:PICKFORD, MALLORY L
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:L
Last Name:PICKFORD
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10800 BRIGHTON BAY BLVD NE
Mailing Address - Street 2:
Mailing Address - City:ST PETERSBURG
Mailing Address - State:FL
Mailing Address - Zip Code:33716-3478
Mailing Address - Country:US
Mailing Address - Phone:843-855-8993
Mailing Address - Fax:
Practice Address - Street 1:6101 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:ST PETERSBURG
Practice Address - State:FL
Practice Address - Zip Code:33710-8529
Practice Address - Country:US
Practice Address - Phone:727-381-4674
Practice Address - Fax:727-341-1182
Is Sole Proprietor?:Yes
Enumeration Date:2023-01-19
Last Update Date:2023-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0200XAmbulatory Health Care FacilitiesClinic/CenterRadiology