Provider Demographics
NPI:1932516945
Name:BLAKESLEE, MALLORY (DO)
Entity Type:Individual
Prefix:DR
First Name:MALLORY
Middle Name:
Last Name:BLAKESLEE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4500 13TH ST
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39501-2569
Mailing Address - Country:US
Mailing Address - Phone:228-575-2000
Mailing Address - Fax:
Practice Address - Street 1:4500 13TH ST
Practice Address - Street 2:
Practice Address - City:GULFPORT
Practice Address - State:MS
Practice Address - Zip Code:39501-2569
Practice Address - Country:US
Practice Address - Phone:228-575-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-07-22
Last Update Date:2020-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK52R207P00000X
MS25885207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine