Provider Demographics
NPI:1710320767
Name:ABATE, MALLORY SHIVER (MD)
Entity Type:Individual
Prefix:DR
First Name:MALLORY
Middle Name:SHIVER
Last Name:ABATE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:MALLORY
Other - Middle Name:BRANNON
Other - Last Name:SHIVER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1008 S SPRING AVE FL 3
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-2520
Mailing Address - Country:US
Mailing Address - Phone:314-977-9711
Mailing Address - Fax:314-977-1802
Practice Address - Street 1:1225 S GRAND BLVD FL 3
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-1016
Practice Address - Country:US
Practice Address - Phone:314-256-3400
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-09
Last Update Date:2021-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2017014176207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty