Provider Demographics
NPI:1447644497
Name:TATE, MALLORY SHURTE (MD)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:SHURTE
Last Name:TATE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:SUSAN
Other - Last Name:SHURTE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3420 KENYON ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-5001
Mailing Address - Country:US
Mailing Address - Phone:877-496-0450
Mailing Address - Fax:
Practice Address - Street 1:3420 KENYON ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-5001
Practice Address - Country:US
Practice Address - Phone:877-496-0450
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-03-26
Last Update Date:2021-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA390200000X
CAA144255174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program