Provider Demographics
NPI:1437449915
Name:PRZYBYLSKI, MALLORY MICHELLE (DPM)
Entity Type:Individual
Prefix:DR
First Name:MALLORY
Middle Name:MICHELLE
Last Name:PRZYBYLSKI
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:212 W MCNEESE ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CHARLES
Mailing Address - State:LA
Mailing Address - Zip Code:70605-5639
Mailing Address - Country:US
Mailing Address - Phone:847-612-9919
Mailing Address - Fax:
Practice Address - Street 1:212 W MCNEESE ST
Practice Address - Street 2:
Practice Address - City:LAKE CHARLES
Practice Address - State:LA
Practice Address - Zip Code:70605-5639
Practice Address - Country:US
Practice Address - Phone:337-474-2233
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-04-18
Last Update Date:2014-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTN/A213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2359495Medicaid
LA2359495Medicaid