MEDICARE: DR. BRENDA F MALLARD MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	101314	MO

General Provider Information

NPI Number	:	1942322250
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BRENDA F MALLARD MD

Provider Business Mailing Address
First Line	:	637 DUNN RD STE 143
Second Line	:
City	:	HAZELWOOD
State	:	MO
Zip	:	63042-1758
Country	:	US
Telephone Number	:	314-409-4595
Fax Number	:

Provider Business Practice Location Address
First Line	:	2880 NETHERTON DR STE 103
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63136-4697
Country	:	US
Telephone Number	:	314-409-4595
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/06/2007
Last Update Date	:	08/14/2025

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