Provider Demographics
NPI:1558674846
Name:LYNCH, MALLORY NICOLE (OD)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:NICOLE
Last Name:LYNCH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 CANYON RIDGE DR STE L300
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78753-1650
Mailing Address - Country:US
Mailing Address - Phone:512-837-3200
Mailing Address - Fax:
Practice Address - Street 1:500 CANYON RIDGE DR STE L300
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78753-1650
Practice Address - Country:US
Practice Address - Phone:512-837-3200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-15
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14353TLG152W00000X
TX7569T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist