Provider Demographics
NPI:1780664201
Name:MALLERY, JOHN A (MD)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:A
Last Name:MALLERY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:150 CATHERINE LANE
Mailing Address - Street 2:#D
Mailing Address - City:GRASS VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:95945
Mailing Address - Country:US
Mailing Address - Phone:530-477-8358
Mailing Address - Fax:530-477-2015
Practice Address - Street 1:150 CATHERINE LANE
Practice Address - Street 2:#D
Practice Address - City:GRASS VALLEY
Practice Address - State:CA
Practice Address - Zip Code:95945
Practice Address - Country:US
Practice Address - Phone:530-477-8358
Practice Address - Fax:530-477-2015
Is Sole Proprietor?:Yes
Enumeration Date:2006-01-19
Last Update Date:2010-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA00G51106207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGR0045980Medicaid
CA00G511061OtherMEDICARE PTAN
A51898Medicare UPIN
CA00G511061OtherMEDICARE PTAN