Basic Information
| Provider Information | |||||||||
| NPI: | 1194165662 | ||||||||
| EntityType: | 1 | ||||||||
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| LastName: | MEYER | ||||||||
| FirstName: | MALLORY | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3333 S BANNOCK ST | ||||||||
| Address2: | STE 350 | ||||||||
| City: | ENGLEWOOD | ||||||||
| State: | CO | ||||||||
| PostalCode: | 801102426 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5156432261 | ||||||||
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| Practice Location | |||||||||
| Address1: | 715 DR MARTIN LUTHER KING JR AVE NE STE 301 | ||||||||
| Address2: | |||||||||
| City: | ALBUQUERQUE | ||||||||
| State: | NM | ||||||||
| PostalCode: | 871023668 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5057277090 | ||||||||
| FaxNumber: | 5057279590 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/28/2013 | ||||||||
| LastUpdateDate: | 07/12/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 07/12/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | R9727 | IA | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | 60839 | CO | N | Allopathic & Osteopathic Physicians | Surgery | 208600000X | A-2513-21 | NM | Y | Allopathic & Osteopathic Physicians | Surgery |
ID Information
| ID | Type | State | Issuer | Description | 9000162980 | 05 | CO | MEDICAID |