Healthcare Provider Details

I. General information

NPI: 1588192520
Provider Name (Legal Business Name): MALLORY DIANE LEWIS DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MALLORY DIANE STREIFFERT

II. Dates (important events)

Enumeration Date: 06/02/2017
Last Update Date: 09/13/2021
Certification Date: 09/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3754 HIGHWAY 90 STE 300
PACE FL
32571-1098
US

IV. Provider business mailing address

4205 BELFORT RD STE 4015
JACKSONVILLE FL
32216-3623
US

V. Phone/Fax

Practice location:
  • Phone: 850-416-5510
  • Fax:
Mailing address:
  • Phone: 904-450-6063
  • Fax: 904-539-4091

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QS0010X
TaxonomySports Medicine (Family Medicine) Physician
License NumberOS17878
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS17878
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: