Provider Demographics
NPI:1689664344
Name:MALLORY, MARIA D (MD)
Entity Type:Individual
Prefix:
First Name:MARIA
Middle Name:D
Last Name:MALLORY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 6TH AVE N
Mailing Address - Street 2:
Mailing Address - City:SAINT CLOUD
Mailing Address - State:MN
Mailing Address - Zip Code:56303-2735
Mailing Address - Country:US
Mailing Address - Phone:320-252-5131
Mailing Address - Fax:320-240-2118
Practice Address - Street 1:1200 6TH AVE N
Practice Address - Street 2:
Practice Address - City:SAINT CLOUD
Practice Address - State:MN
Practice Address - Zip Code:56303-2735
Practice Address - Country:US
Practice Address - Phone:320-252-5131
Practice Address - Fax:320-240-2118
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN47718208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
1043623OtherPREFERRED ONE
HP52031OtherHEALTH PARTNERS
1701414OtherMEDICA HEALTH PLANS
346G4MAOtherBLUE CROSS BLUE SHIELD
132828OtherU CARE
2357287OtherARAZ GROUP AMERICAS PPO
6D053CEOtherBLUE CROSS BLUE SHIELD
754479100OtherMEDICAL ASSISTANCE
1701414OtherMEDICA HEALTH PLANS
I36624Medicare UPIN