Provider Demographics
NPI:1528357506
Name:O'NIEL, MALLORY BROOKE
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:BROOKE
Last Name:O'NIEL
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 1:3901 BEAUBIEN ST STE 2102
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48201-2119
Mailing Address - Country:US
Mailing Address - Phone:313-745-9048
Mailing Address - Fax:313-993-3879
Practice Address - Street 1:3901 BEAUBIEN ST STE 2102
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48201-2119
Practice Address - Country:US
Practice Address - Phone:313-745-9048
Practice Address - Fax:313-993-3879
Is Sole Proprietor?:No
Enumeration Date:2011-03-30
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
MI4301112964207YP0228X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207YP0228XAllopathic & Osteopathic PhysiciansOtolaryngologyPediatric Otolaryngology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program