Provider Demographics
NPI:1194145532
Name:MALLORY, MATTHEW LAYNE (MD)
Entity type:Individual
Prefix:
First Name:MATTHEW
Middle Name:LAYNE
Last Name:MALLORY
Suffix:
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 1:222 E DUNBAR LN APT 326
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:AR
Mailing Address - Zip Code:72703-3276
Mailing Address - Country:US
Mailing Address - Phone:434-258-4408
Mailing Address - Fax:479-587-1366
Practice Address - Street 1:60 E MONTE PAINTER DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-4014
Practice Address - Country:US
Practice Address - Phone:479-587-1700
Practice Address - Fax:479-587-1366
Is Sole Proprietor?:No
Enumeration Date:2014-04-24
Last Update Date:2024-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04420722085R0001X
MO20190244432085R0001X
390200000X
ARE-144742085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200993230AMedicaid
AR269386001Medicaid