Healthcare Provider Details

I. General information

NPI: 1033851084
Provider Name (Legal Business Name): MALLORY JANE OGBURN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2022
Last Update Date: 04/11/2022
Certification Date: 04/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4502 MEDICAL DR
SAN ANTONIO TX
78229-4492
US

IV. Provider business mailing address

709 S G ST
MCALLEN TX
78501-8806
US

V. Phone/Fax

Practice location:
  • Phone: 210-358-4000
  • Fax:
Mailing address:
  • Phone: 505-239-7968
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: