Provider Demographics
NPI:1871771410
Name:MALLORY, ROSLYN V (MD)
Entity type:Individual
Prefix:
First Name:ROSLYN
Middle Name:V
Last Name:MALLORY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:70 DOCTORS DR
Mailing Address - Street 2:
Mailing Address - City:PANAMA CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32405-4517
Mailing Address - Country:US
Mailing Address - Phone:850-785-1517
Mailing Address - Fax:850-784-1271
Practice Address - Street 1:70 DOCTORS DR
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-4517
Practice Address - Country:US
Practice Address - Phone:850-785-1517
Practice Address - Fax:850-784-1271
Is Sole Proprietor?:No
Enumeration Date:2008-02-06
Last Update Date:2014-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME107856207V00000X, 207VG0400X, 207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL149F4OtherBCBS
FL002800000Medicaid
FLDN309ZMedicare PIN