Provider Demographics
NPI:1992069777
Name:MALLORY, BRADY (DPM)
Entity type:Individual
Prefix:
First Name:BRADY
Middle Name:
Last Name:MALLORY
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1940 HWY 114 SUITE 150
Mailing Address - Street 2:
Mailing Address - City:SOUTHLAKE
Mailing Address - State:TX
Mailing Address - Zip Code:76092
Mailing Address - Country:US
Mailing Address - Phone:817-424-3668
Mailing Address - Fax:817-442-8637
Practice Address - Street 1:1940 EAST HWY 114 SUITE 150
Practice Address - Street 2:
Practice Address - City:SOUTHLAKE
Practice Address - State:TX
Practice Address - Zip Code:76092
Practice Address - Country:US
Practice Address - Phone:817-424-3668
Practice Address - Fax:817-442-8637
Is Sole Proprietor?:No
Enumeration Date:2012-06-27
Last Update Date:2016-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC006356213EP1101X, 213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1932493574OtherNPI
TX1932493574OtherNPI
TX900170193OtherTIN