Healthcare Provider Details

I. General information

NPI: 1871771410
Provider Name (Legal Business Name): ROSLYN V MALLORY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2008
Last Update Date: 01/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

70 DOCTORS DR
PANAMA CITY FL
32405-4517
US

IV. Provider business mailing address

70 DOCTORS DR
PANAMA CITY FL
32405-4517
US

V. Phone/Fax

Practice location:
  • Phone: 850-785-1517
  • Fax: 850-784-1271
Mailing address:
  • Phone: 850-785-1517
  • Fax: 850-784-1271

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberME107856
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberME107856
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207VX0000X
TaxonomyObstetrics Physician
License NumberME107856
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: