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General NPI Number Information
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NPI Number | 1992069777
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Entity Type | Individual
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Provider Name | BRADY MALLORY D.P.M.
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Gender | Male
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Dates
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Enumeration Date | 06/27/2012
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Last Update Date | 12/13/2016
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Provider Practice Location Address
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Address Line | 1940 EAST HWY 114 SUITE 150
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City | SOUTHLAKE
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State | TX
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Zip | 76092
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Country | US
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Telephone | 817-424-3668
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Fax | 817-442-8637
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Provider Business Mailing Address
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Address Line | 1940 HWY 114 SUITE 150
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City | SOUTHLAKE
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State | TX
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Zip | 76092
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Country | US
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Telephone | 817-424-3668
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Fax | 817-442-8637
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213EP1101X
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Taxonomy Name | Primary Podiatric Medicine Podiatrist
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License Number | SC006356
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License Number State | PA
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Taxonomy #2
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Taxonomy Code | 213ES0103X
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Taxonomy Name | Foot & Ankle Surgery Podiatrist
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License Number | SC006356
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License Number State | PA
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