Provider Demographics
NPI:1023012739
Name:MALLORY, DANIEL H (OD)
Entity type:Individual
Prefix:DR
First Name:DANIEL
Middle Name:H
Last Name:MALLORY
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1409 N NORMA ST
Mailing Address - Street 2:
Mailing Address - City:RIDGECREST
Mailing Address - State:CA
Mailing Address - Zip Code:93555-2510
Mailing Address - Country:US
Mailing Address - Phone:760-446-5555
Mailing Address - Fax:790-446-2905
Practice Address - Street 1:1409 N NORMA ST
Practice Address - Street 2:
Practice Address - City:RIDGECREST
Practice Address - State:CA
Practice Address - Zip Code:93555-2510
Practice Address - Country:US
Practice Address - Phone:760-446-5555
Practice Address - Fax:790-446-2905
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-09
Last Update Date:2022-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT7267TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA953703868 93555 A001OtherTRICARE
CASD0072671Medicaid
CASD0072671Medicaid
CAT10504Medicare UPIN
CASD0072671Medicare ID - Type Unspecified