Healthcare Provider Details

I. General information

NPI: 1316545304
Provider Name (Legal Business Name): VICTOR THEODORE MALLORY PA-C
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2020
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 N ACADEMY AVE
DANVILLE PA
17822-9800
US

IV. Provider business mailing address

PO BOX 13579
READING PA
19612-3579
US

V. Phone/Fax

Practice location:
  • Phone: 570-271-6211
  • Fax:
Mailing address:
  • Phone: 215-427-4820
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License NumberMA061966
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: