Provider Demographics
NPI:1336375369
Name:MALLORY, SAMANTHA L (MD)
Entity Type:Individual
Prefix:
First Name:SAMANTHA
Middle Name:L
Last Name:MALLORY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1215 PLEASANT ST STE 514
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50309-1418
Mailing Address - Country:US
Mailing Address - Phone:515-241-8912
Mailing Address - Fax:515-241-8988
Practice Address - Street 1:1215 PLEASANT ST STE 514
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50309-1418
Practice Address - Country:US
Practice Address - Phone:515-241-8912
Practice Address - Fax:515-241-8988
Is Sole Proprietor?:No
Enumeration Date:2009-06-04
Last Update Date:2016-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK27050208000000X
IAMD-434662080P0207X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0207XAllopathic & Osteopathic PhysiciansPediatricsPediatric Hematology-Oncology
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1336375369Medicaid
IA1336375369Medicaid