Provider Demographics
NPI:1073923132
Name:LOSTUMBO, MALLORY
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:LOSTUMBO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6201 GREENLEIGH AVE
Mailing Address - Street 2:
Mailing Address - City:MIDDLE RIVER
Mailing Address - State:MD
Mailing Address - Zip Code:21220-2004
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:240-236-9865
Practice Address - Street 1:1201 SEVEN LOCKS RD STE 201
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20854-2963
Practice Address - Country:US
Practice Address - Phone:301-881-7995
Practice Address - Fax:240-236-9865
Is Sole Proprietor?:No
Enumeration Date:2014-04-29
Last Update Date:2025-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD83313208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics