Provider Demographics
NPI:1912388687
Name:REEVES, MALLORY (DO)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:REEVES
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:
Other - Last Name:RAPER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:1606 MCARTHUR ST
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:TN
Mailing Address - Zip Code:37355-2522
Mailing Address - Country:US
Mailing Address - Phone:931-723-2036
Mailing Address - Fax:
Practice Address - Street 1:1606 MCARTHUR ST
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:TN
Practice Address - Zip Code:37355-2522
Practice Address - Country:US
Practice Address - Phone:931-723-2036
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-06-17
Last Update Date:2023-04-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN3132208D00000X, 208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
HIVAD000Medicare UPIN