Provider Demographics
NPI:1831205723
Name:MALLORY, SUSAN R (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:R
Last Name:MALLORY
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:2133 KODIAK DR NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30345-4149
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:445 WINN WAY
Practice Address - Street 2:DEKALB COMMUNITY SERVICE BOARD WINN WAY MHC
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30030
Practice Address - Country:US
Practice Address - Phone:404-294-7700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2014-04-04
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GA0554252084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCHO2370Medicare UPIN