Provider Demographics
NPI:1417712589
Name:MALLORY, LUKE T (DPT)
Entity Type:Individual
Prefix:
First Name:LUKE
Middle Name:T
Last Name:MALLORY
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:16658 N HIGHWAY 41
Mailing Address - Street 2:
Mailing Address - City:RATHDRUM
Mailing Address - State:ID
Mailing Address - Zip Code:83858-6890
Mailing Address - Country:US
Mailing Address - Phone:208-687-9195
Mailing Address - Fax:208-687-9750
Practice Address - Street 1:16658 N HIGHWAY 41
Practice Address - Street 2:
Practice Address - City:RATHDRUM
Practice Address - State:ID
Practice Address - Zip Code:83858-6890
Practice Address - Country:US
Practice Address - Phone:208-687-9195
Practice Address - Fax:208-687-9750
Is Sole Proprietor?:No
Enumeration Date:2024-02-19
Last Update Date:2024-02-27
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IDPT-8974208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation