Provider Demographics
NPI:1396793733
Name:MALLOW, WILLIAM OLIN (MD)
Entity type:Individual
Prefix:DR
First Name:WILLIAM
Middle Name:OLIN
Last Name:MALLOW
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 1:2700 MCCALL CT
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:GA
Mailing Address - Zip Code:31721-9193
Mailing Address - Country:US
Mailing Address - Phone:864-344-0265
Mailing Address - Fax:
Practice Address - Street 1:803 N JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:GA
Practice Address - Zip Code:31701-2373
Practice Address - Country:US
Practice Address - Phone:229-312-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC16019207P00000X, 207Q00000X
GA056900207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003122498FMedicaid
SC160195Medicaid
SC1124Medicare PIN
SC9337Medicare PIN
SCF039941124Medicare PIN
SC160195Medicaid
GA202I939022Medicare Oscar/Certification