Basic Information
| Provider Information | |||||||||
| NPI: | 1093197188 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MALLORY | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | ROBERT | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 213 S JEFFERSON ST STE 1006 | ||||||||
| Address2: | |||||||||
| City: | ROANOKE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 240111713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5402245715 | ||||||||
| FaxNumber: | 5402245684 | ||||||||
| Practice Location | |||||||||
| Address1: | 2050 VERSAILLES RD | ||||||||
| Address2: | |||||||||
| City: | LEXINGTON | ||||||||
| State: | KY | ||||||||
| PostalCode: | 405041405 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8592574888 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/24/2015 | ||||||||
| LastUpdateDate: | 08/11/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/11/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208100000X | R4130 | KY | Y | Allopathic & Osteopathic Physicians | Physical Medicine & Rehabilitation | 208600000X | 1232284 | SC | N | Allopathic & Osteopathic Physicians | Surgery |
No ID Information.