Provider Demographics
NPI:1790786358
Name:MALLY, MITCHELL ROBERT (DC)
Entity Type:Individual
Prefix:DR
First Name:MITCHELL
Middle Name:ROBERT
Last Name:MALLY
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3400 DEXTER CT STE 105
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-3462
Mailing Address - Country:US
Mailing Address - Phone:563-823-5555
Mailing Address - Fax:563-823-5556
Practice Address - Street 1:3400 DEXTER CT STE 105
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807
Practice Address - Country:US
Practice Address - Phone:563-823-5555
Practice Address - Fax:563-823-5556
Is Sole Proprietor?:No
Enumeration Date:2005-08-04
Last Update Date:2018-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA04853111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1192278Medicaid
IAT01112Medicare UPIN
IAI7876Medicare ID - Type Unspecified