Healthcare Provider Details

I. General information

NPI: 1366515645
Provider Name (Legal Business Name): STEPHEN MALLARY MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/16/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

567 ARLINGTON PL
MACON GA
31201-1704
US

IV. Provider business mailing address

567 ARLINGTON PL
MACON GA
31201-1704
US

V. Phone/Fax

Practice location:
  • Phone: 478-745-9206
  • Fax: 478-738-0758
Mailing address:
  • Phone: 478-745-9206
  • Fax: 478-738-0758

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number028600
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: