Healthcare Provider Details

I. General information

NPI: 1730107400
Provider Name (Legal Business Name): SUSAN L MALLORY M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 05/09/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6480 PENTZ RD SUITE E
PARADISE CA
95969-3672
US

IV. Provider business mailing address

6470 PENTZ RD SUITE A
PARADISE CA
95969-3674
US

V. Phone/Fax

Practice location:
  • Phone: 530-877-5437
  • Fax: 530-877-5692
Mailing address:
  • Phone: 530-872-6650
  • Fax: 530-872-6653

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberG78212
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: