Provider Demographics
NPI:1427324185
Name:NOVACK, MALLORY E (DO)
Entity type:Individual
Prefix:DR
First Name:MALLORY
Middle Name:E
Last Name:NOVACK
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 1:10273 NORTHRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91737-3042
Mailing Address - Country:US
Mailing Address - Phone:406-498-1090
Mailing Address - Fax:
Practice Address - Street 1:400 N PEPPER AVE # 206
Practice Address - Street 2:
Practice Address - City:COLTON
Practice Address - State:CA
Practice Address - Zip Code:92324-1801
Practice Address - Country:US
Practice Address - Phone:909-580-2270
Practice Address - Fax:909-580-3289
Is Sole Proprietor?:No
Enumeration Date:2012-03-27
Last Update Date:2024-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MT49924207V00000X
CA20A13191207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MT1427324185OtherNPI
MT1427324185Medicaid