Provider Demographics
NPI:1336254218
Name:MALLORY, HARVEY E IV (MD)
Entity Type:Individual
Prefix:
First Name:HARVEY
Middle Name:E
Last Name:MALLORY
Suffix:IV
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 95590
Mailing Address - Street 2:
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87199-5590
Mailing Address - Country:US
Mailing Address - Phone:505-818-9247
Mailing Address - Fax:505-217-3950
Practice Address - Street 1:7000 JEFFERSON ST NE
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87109-4313
Practice Address - Country:US
Practice Address - Phone:505-344-9478
Practice Address - Fax:505-344-2783
Is Sole Proprietor?:No
Enumeration Date:2006-08-20
Last Update Date:2014-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMMD2006-0166208100000X, 207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM2006-0166OtherLICENSE NUMBER