Provider Demographics
NPI:1871117598
Name:MALLORY, BRIAN L (MD)
Entity type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:L
Last Name:MALLORY
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 1:3601 4TH ST STOP 6207
Mailing Address - Street 2:
Mailing Address - City:LUBBOCK
Mailing Address - State:TX
Mailing Address - Zip Code:79430-6207
Mailing Address - Country:US
Mailing Address - Phone:806-743-2757
Mailing Address - Fax:
Practice Address - Street 1:3601 4TH ST STOP 6207
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79430-6207
Practice Address - Country:US
Practice Address - Phone:806-743-2757
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-29
Last Update Date:2024-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXV3904207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine