Provider Demographics
NPI:1942763420
Name:MALLORY, CHRISTOPHER M (MD, MS, MHA)
Entity Type:Individual
Prefix:
First Name:CHRISTOPHER
Middle Name:M
Last Name:MALLORY
Suffix:
Gender:M
Credentials:MD, MS, MHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 N 1900 E RM 1A071
Mailing Address - Street 2:
Mailing Address - City:SALT LAKE CITY
Mailing Address - State:UT
Mailing Address - Zip Code:84132-0002
Mailing Address - Country:US
Mailing Address - Phone:801-581-2868
Mailing Address - Fax:
Practice Address - Street 1:30 N 1900 E RM 1A071
Practice Address - Street 2:
Practice Address - City:SALT LAKE CITY
Practice Address - State:UT
Practice Address - Zip Code:84132-0002
Practice Address - Country:US
Practice Address - Phone:801-581-2868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-10
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDMRM-1803207R00000X
UT11901378-12052085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine