Provider Demographics
NPI:1568690477
Name:MALLORY, GRANT W (MD)
Entity type:Individual
Prefix:
First Name:GRANT
Middle Name:W
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 1:25507 WESLEY PARK
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78261-2720
Mailing Address - Country:US
Mailing Address - Phone:303-803-6953
Mailing Address - Fax:
Practice Address - Street 1:200 1ST ST SW
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:MN
Practice Address - Zip Code:55905-0002
Practice Address - Country:US
Practice Address - Phone:303-803-6953
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-30
Last Update Date:2024-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI81713207T00000X
WI100503207T00000X
MN53091207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNENROLLEDMedicaid
IAENROLLEDMedicaid
IAENROLLEDMedicaid