Provider Demographics
NPI:1255646907
Name:MALLARD, CHRISTOPHER CARMAN (OD)
Entity type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:CARMAN
Last Name:MALLARD
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 1:4959 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:SPRING HILL
Mailing Address - State:TN
Mailing Address - Zip Code:37174-2727
Mailing Address - Country:US
Mailing Address - Phone:615-302-4477
Mailing Address - Fax:615-302-4485
Practice Address - Street 1:4959 MAIN ST
Practice Address - Street 2:
Practice Address - City:SPRING HILL
Practice Address - State:TN
Practice Address - Zip Code:37174-2727
Practice Address - Country:US
Practice Address - Phone:615-302-4477
Practice Address - Fax:615-302-4485
Is Sole Proprietor?:Yes
Enumeration Date:2010-08-18
Last Update Date:2013-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2955152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103I415515Medicare PIN