Healthcare Provider Details

I. General information

NPI: 1588612667
Provider Name (Legal Business Name): ROBERT J MALLORY MSPH, MPAS, PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2006
Last Update Date: 04/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W ARBOR DR
SAN DIEGO CA
92103-9000
US

IV. Provider business mailing address

PO BOX 232410
SAN DIEGO CA
92193-2410
US

V. Phone/Fax

Practice location:
  • Phone: 858-246-1597
  • Fax: 858-228-5153
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363AS0400X
TaxonomySurgical Physician Assistant
License NumberPA16538
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: