Provider Demographics
NPI:1366515645
Name:MALLARY, STEPHEN (MD)
Entity type:Individual
Prefix:
First Name:STEPHEN
Middle Name:
Last Name:MALLARY
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:567 ARLINGTON PL
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-1704
Mailing Address - Country:US
Mailing Address - Phone:478-745-9206
Mailing Address - Fax:478-738-0758
Practice Address - Street 1:567 ARLINGTON PL
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-1704
Practice Address - Country:US
Practice Address - Phone:478-745-9206
Practice Address - Fax:478-738-0758
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0286002084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA26BDDFNMedicare ID - Type Unspecified