Provider Demographics
NPI:1821090556
Name:MALLORY, DAVID (MD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:MALLORY
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 1:5700 MONROE ST UNIT 206
Mailing Address - Street 2:
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-2735
Mailing Address - Country:US
Mailing Address - Phone:419-473-6601
Mailing Address - Fax:419-479-6966
Practice Address - Street 1:5700 MONROE ST UNIT 206
Practice Address - Street 2:
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560-2735
Practice Address - Country:US
Practice Address - Phone:419-473-6601
Practice Address - Fax:419-479-6966
Is Sole Proprietor?:No
Enumeration Date:2005-08-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35050597207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH00234OtherPARAMOUNT
OH080130446OtherRRMC
OH0633929OtherAETNA
OH000000141191OtherANTHEM
OH0565115Medicaid
OH01-03316OtherUHC
OH0565115Medicaid
OH000000141191OtherANTHEM