Provider Demographics
NPI:1659952323
Name:MALLOW, GARY MICHAEL
Entity Type:Individual
Prefix:
First Name:GARY
Middle Name:MICHAEL
Last Name:MALLOW
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:710 W 14TH ST APT 317
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60607-5101
Mailing Address - Country:US
Mailing Address - Phone:954-383-7454
Mailing Address - Fax:
Practice Address - Street 1:1120 15TH ST
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30912-0006
Practice Address - Country:US
Practice Address - Phone:954-383-7454
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-04-15
Last Update Date:2021-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program