Provider Demographics
NPI:1871956870
Name:YOUNGSTROM, MALLORY LYNN (MD)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:LYNN
Last Name:YOUNGSTROM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:682 HEMLOCK ST STE 210
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31201-8314
Mailing Address - Country:US
Mailing Address - Phone:478-633-5300
Mailing Address - Fax:478-633-5304
Practice Address - Street 1:682 HEMLOCK ST STE 210
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31201-8314
Practice Address - Country:US
Practice Address - Phone:478-633-5300
Practice Address - Fax:478-633-5304
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-29
Last Update Date:2024-06-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA85686207V00000X, 207VF0040X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VF0040XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyUrogynecology and Reconstructive Pelvic Surgery
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology