Provider Demographics
NPI:1831139039
Name:MALLORY, DOROTHY JILL (MD)
Entity Type:Individual
Prefix:DR
First Name:DOROTHY
Middle Name:JILL
Last Name:MALLORY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:251 E COTTAGE GROVE RD
Mailing Address - Street 2:
Mailing Address - City:COTTAGE GROVE
Mailing Address - State:WI
Mailing Address - Zip Code:53527-9619
Mailing Address - Country:US
Mailing Address - Phone:608-839-3515
Mailing Address - Fax:608-839-3541
Practice Address - Street 1:251 E COTTAGE GROVE RD
Practice Address - Street 2:
Practice Address - City:COTTAGE GROVE
Practice Address - State:WI
Practice Address - Zip Code:53527-9619
Practice Address - Country:US
Practice Address - Phone:608-839-3515
Practice Address - Fax:608-839-3541
Is Sole Proprietor?:No
Enumeration Date:2006-06-07
Last Update Date:2020-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI49462-020207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI34734300Medicaid
WI151150020OtherMEDICARE PTAN