Provider Demographics
NPI:1386677722
Name:MALLORY, CHERYL A (MD)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:A
Last Name:MALLORY
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 1:2315 8TH ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ID
Mailing Address - Zip Code:83501-7301
Mailing Address - Country:US
Mailing Address - Phone:208-746-1383
Mailing Address - Fax:208-746-6348
Practice Address - Street 1:2315 8TH ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ID
Practice Address - Zip Code:83501-7301
Practice Address - Country:US
Practice Address - Phone:208-746-1383
Practice Address - Fax:208-746-6348
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2015-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMD000637598207Q00000X
IDM-10915207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1386677722OtherREGENCE BLUESHIELD
ID1386677722Medicaid
WA1009174Medicaid
WA177340OtherL&I
WA307956OtherL & I MEDICAL PROVIDER NETWORK
ID20001487Medicare PIN
WA8800123Medicare PIN
WA307956OtherL & I MEDICAL PROVIDER NETWORK