Provider Demographics
NPI:1740555002
Name:NAGARAH, MALLORY CHRISTINE (DO)
Entity type:Individual
Prefix:DR
First Name:MALLORY
Middle Name:CHRISTINE
Last Name:NAGARAH
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:1640 FORT ST SUITE D
Mailing Address - Street 2:ATTN DENISE
Mailing Address - City:TRENTON
Mailing Address - State:MI
Mailing Address - Zip Code:48183
Mailing Address - Country:US
Mailing Address - Phone:734-391-3057
Mailing Address - Fax:734-391-3052
Practice Address - Street 1:15675 NORTHLINE RD
Practice Address - Street 2:
Practice Address - City:SOUTHGATE
Practice Address - State:MI
Practice Address - Zip Code:48195-2334
Practice Address - Country:US
Practice Address - Phone:734-282-3600
Practice Address - Fax:734-282-3603
Is Sole Proprietor?:No
Enumeration Date:2012-03-19
Last Update Date:2017-02-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI5101019837207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0H24657OtherBLUE CROSS
1457586646OtherGROUP NPI HENRY FORD WYANDOTTE
MI0H24657OtherBLUE CROSS