MEDICARE: MARY BRADEN HENDON MALLORY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	S-F49-TA-D48	AL

General Provider Information

NPI Number	:	1386483394
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY BRADEN HENDON MALLORY

Provider Business Mailing Address
First Line	:	1009 MONTGOMERY HWY
Second Line	:
City	:	VESTAVIA HILLS
State	:	AL
Zip	:	35216-2831
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1009 MONTGOMERY HWY
Second Line	:
City	:	VESTAVIA HILLS
State	:	AL
Zip	:	35216-2831
Country	:	US
Telephone Number	:	205-397-9400
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/20/2024
Last Update Date	:	03/31/2026

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