Provider Demographics
NPI:1194780874
Name:MALLOW, L SUZANNE (MD)
Entity type:Individual
Prefix:DR
First Name:L
Middle Name:SUZANNE
Last Name:MALLOW
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:600 E PALMETTO ST
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:SC
Mailing Address - Zip Code:29506-2851
Mailing Address - Country:US
Mailing Address - Phone:843-667-9414
Mailing Address - Fax:843-667-1282
Practice Address - Street 1:600 E PALMETTO ST
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:SC
Practice Address - Zip Code:29506-2851
Practice Address - Country:US
Practice Address - Phone:843-667-9414
Practice Address - Fax:843-667-1282
Is Sole Proprietor?:No
Enumeration Date:2006-04-18
Last Update Date:2011-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC12722207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC127222Medicaid
SC127222Medicaid