1427324185 NPI number — DR. MALLORY E NOVACK D.O.

Table of content: DR. MALLORY E NOVACK D.O. (NPI 1427324185)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1427324185 NPI number — DR. MALLORY E NOVACK D.O.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
NOVACK
Provider First Name:
MALLORY
Provider Middle Name:
E
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
D.O.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1427324185
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/19/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10273 NORTHRIDGE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RANCHO CUCAMONGA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91737-3042
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
406-498-1090
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 N PEPPER AVE # 206
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COLTON
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92324-1801
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
909-580-2270
Provider Business Practice Location Address Fax Number:
909-580-3289
Provider Enumeration Date:
03/27/2012

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  49924 , registered in the state of MT ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 20A13191 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1427324185 . This is a "NPI" identifier , issued by the state of ( MT ) . This identifiers is of the category "OTHER".
  • Identifier: 1427324185 , issued by the state of ( MT ) . This identifiers is of the category "MEDICAID".




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