Provider Demographics
NPI:1699881359
Name:MALLON, MICHAELA RUTH (MD)
Entity type:Individual
Prefix:DR
First Name:MICHAELA
Middle Name:RUTH
Last Name:MALLON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5675 ROE BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:ROELAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66205-2538
Mailing Address - Country:US
Mailing Address - Phone:913-432-2080
Mailing Address - Fax:
Practice Address - Street 1:9300 MEADOW VIEW DR
Practice Address - Street 2:
Practice Address - City:SHAWNEE
Practice Address - State:KS
Practice Address - Zip Code:66227-7288
Practice Address - Country:US
Practice Address - Phone:913-601-4500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-22
Last Update Date:2024-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS04-28114207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL276639600Medicaid
FLAC410YMedicare PIN
FLG20847Medicare UPIN