Healthcare Provider Details

I. General information

NPI: 1194145532
Provider Name (Legal Business Name): MATTHEW LAYNE MALLORY M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/24/2014
Last Update Date: 10/08/2024
Certification Date: 10/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

60 E MONTE PAINTER DR
FAYETTEVILLE AR
72703-4014
US

IV. Provider business mailing address

222 E DUNBAR LN APT 326
FAYETTEVILLE AR
72703-3276
US

V. Phone/Fax

Practice location:
  • Phone: 479-587-1700
  • Fax: 479-587-1366
Mailing address:
  • Phone: 434-258-4408
  • Fax: 479-587-1366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number0442072
License Number StateKS
# 2
Primary TaxonomyN
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License Number2019024443
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code2085R0001X
TaxonomyRadiation Oncology Physician
License NumberE-14474
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: