Provider Demographics
NPI:1215921929
Name:MALLORY, JOHN A (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:A
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 1:10601 QUIVIRA RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66215-2310
Mailing Address - Country:US
Mailing Address - Phone:913-541-3340
Mailing Address - Fax:913-492-7857
Practice Address - Street 1:10601 QUIVIRA RD
Practice Address - Street 2:SUITE 200
Practice Address - City:OVERLAND PARK
Practice Address - State:KS
Practice Address - Zip Code:66215-2310
Practice Address - Country:US
Practice Address - Phone:913-541-3340
Practice Address - Fax:913-492-7857
Is Sole Proprietor?:No
Enumeration Date:2005-09-08
Last Update Date:2009-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-16146207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1215921929Medicaid
KS100093790CMedicaid
KS04-16146OtherMEDICAL LICENSE
MO33495OtherMEDICAL LICENSE
KSS293497Medicare PIN
KSC51127Medicare UPIN