Provider Demographics
NPI:1194165662
Name:MEYER, MALLORY (DO)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:
Last Name:MEYER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3333 S BANNOCK ST
Mailing Address - Street 2:STE 350
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80110-2426
Mailing Address - Country:US
Mailing Address - Phone:515-643-2261
Mailing Address - Fax:
Practice Address - Street 1:715 DR MARTIN LUTHER KING JR AVE NE STE 301
Practice Address - Street 2:
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87102-3668
Practice Address - Country:US
Practice Address - Phone:505-727-7090
Practice Address - Fax:505-727-9590
Is Sole Proprietor?:No
Enumeration Date:2013-06-28
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IAR9727208600000X
CO60839208600000X
NMA-2513-21208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO9000162980Medicaid