=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477580397
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | VICTORIA MALLON MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/27/2006
-----------------------------------------------------
Last Update Date | 02/24/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 300 COLORADO AVE
-----------------------------------------------------
City | PUEBLO
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81004-2006
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-543-8711
-----------------------------------------------------
Fax | 719-543-5340
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 310 COLORADO AVE
-----------------------------------------------------
City | PUEBLO
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 81004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 719-543-8718
-----------------------------------------------------
Fax | 719-543-5340
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 39730
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------