Healthcare Provider Details

I. General information

NPI: 1669032082
Provider Name (Legal Business Name): MATTHEW S MALLARD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2019
Last Update Date: 07/30/2023
Certification Date: 07/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1600 SW ARCHER RD
GAINESVILLE FL
32610-5665
US

IV. Provider business mailing address

701 GROVE RD FL 3
GREENVILLE SC
29605-4295
US

V. Phone/Fax

Practice location:
  • Phone: 352-273-8610
  • Fax:
Mailing address:
  • Phone: 864-455-1435
  • Fax: 864-455-1320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberLL82869
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberME162398
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: