Healthcare Provider Details

I. General information

NPI: 1780664201
Provider Name (Legal Business Name): JOHN A MALLERY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 04/22/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 CATHERINE LANE #D
GRASS VALLEY CA
95945
US

IV. Provider business mailing address

150 CATHERINE LANE #D
GRASS VALLEY CA
95945
US

V. Phone/Fax

Practice location:
  • Phone: 530-477-8358
  • Fax: 530-477-2015
Mailing address:
  • Phone: 530-477-8358
  • Fax: 530-477-2015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License Number00G51106
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: