Healthcare Provider Details

I. General information

NPI: 1487399309
Provider Name (Legal Business Name): MALLORY BAGWELL DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2022
Last Update Date: 07/18/2025
Certification Date: 07/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2302 COLLEGE AVE STE 100
CONWAY AR
72034-6297
US

IV. Provider business mailing address

PO BOX 9662
CONWAY AR
72033-9662
US

V. Phone/Fax

Practice location:
  • Phone: 501-513-5385
  • Fax: 501-513-5257
Mailing address:
  • Phone: 501-852-1363
  • Fax: 501-852-1363

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberE18728
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: