Provider Demographics
NPI:1215918503
Name:MALLORY, VINCENT D (MD)
Entity type:Individual
Prefix:DR
First Name:VINCENT
Middle Name:D
Last Name:MALLORY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:VINCENT
Other - Middle Name:D
Other - Last Name:MALLORY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD LLC
Mailing Address - Street 1:2495 SHREVEPORT HWY
Mailing Address - Street 2:
Mailing Address - City:PINEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71360-4044
Mailing Address - Country:US
Mailing Address - Phone:318-466-2106
Mailing Address - Fax:
Practice Address - Street 1:2495 SHREVEPORT HWY
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:LA
Practice Address - Zip Code:71360-4044
Practice Address - Country:US
Practice Address - Phone:318-466-2106
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-14
Last Update Date:2023-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA015979207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1574520Medicaid
LA1574520Medicaid
4E080Medicare ID - Type Unspecified