Healthcare Provider Details

I. General information

NPI: 1386746857
Provider Name (Legal Business Name): KEITH ALLEN MALLATT O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/03/2006
Last Update Date: 11/25/2024
Certification Date: 11/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

719 E 7TH ST
GALENA KS
66739-1703
US

IV. Provider business mailing address

PO BOX 185
GALENA KS
66739-0185
US

V. Phone/Fax

Practice location:
  • Phone: 620-783-2191
  • Fax: 620-783-1937
Mailing address:
  • Phone: 620-783-2191
  • Fax: 620-783-1937

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberKS 1173-2
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: