Provider Demographics
NPI:1467987727
Name:KOULA, MALLORY (MD)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:KOULA
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:PO BOX 12
Mailing Address - Street 2:
Mailing Address - City:LIBERTY LAKE
Mailing Address - State:WA
Mailing Address - Zip Code:99019-0012
Mailing Address - Country:US
Mailing Address - Phone:406-327-1850
Mailing Address - Fax:406-327-1875
Practice Address - Street 1:3075 N RESERVE ST STE Q
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59808-1390
Practice Address - Country:US
Practice Address - Phone:406-327-1850
Practice Address - Fax:406-327-1875
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-25
Last Update Date:2022-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT10983218-12052085R0202X
MTMED-PHYS-LIC-114887207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology