Provider Demographics
NPI:1730107400
Name:MALLORY, SUSAN L (MD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:L
Last Name:MALLORY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:6470 PENTZ RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:PARADISE
Mailing Address - State:CA
Mailing Address - Zip Code:95969-3674
Mailing Address - Country:US
Mailing Address - Phone:530-872-6650
Mailing Address - Fax:530-872-6653
Practice Address - Street 1:6480 PENTZ RD
Practice Address - Street 2:SUITE E
Practice Address - City:PARADISE
Practice Address - State:CA
Practice Address - Zip Code:95969-3672
Practice Address - Country:US
Practice Address - Phone:530-877-5437
Practice Address - Fax:530-877-5692
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2011-05-09
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAG78212208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ01920ZOtherBLUE SHIELD
CAG10641Medicare UPIN