Healthcare Provider Details

I. General information

NPI: 1134533102
Provider Name (Legal Business Name): CHRISTOPHER MALLARD M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/17/2014
Last Update Date: 06/17/2022
Certification Date: 06/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 GREATSTONE PT STE A100
LEXINGTON KY
40504-3274
US

IV. Provider business mailing address

5710 OLEANDER DR STE 201
WILMINGTON NC
28403-4722
US

V. Phone/Fax

Practice location:
  • Phone: 859-323-7246
  • Fax: 859-257-6768
Mailing address:
  • Phone: 333-657-2468
  • Fax: 910-338-0909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number51522
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License NumberR3550
License Number StateKY
# 3
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number51522
License Number StateKY
# 4
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number83081
License Number StateSC
# 5
Primary TaxonomyN
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number2019-00963
License Number StateNC
# 6
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number51522
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: