Basic Information
| Provider Information | |||||||||
| NPI: | 1467987727 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KOULA | ||||||||
| FirstName: | MALLORY | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 12 | ||||||||
| Address2: | |||||||||
| City: | LIBERTY LAKE | ||||||||
| State: | WA | ||||||||
| PostalCode: | 990190012 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4063271850 | ||||||||
| FaxNumber: | 4063271875 | ||||||||
| Practice Location | |||||||||
| Address1: | 3075 N RESERVE ST STE Q | ||||||||
| Address2: | |||||||||
| City: | MISSOULA | ||||||||
| State: | MT | ||||||||
| PostalCode: | 598081390 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4063271850 | ||||||||
| FaxNumber: | 4063271875 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/25/2017 | ||||||||
| LastUpdateDate: | 09/27/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 09/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2085R0202X | 10983218-1205 | UT | N | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology | 207Q00000X | MED-PHYS-LIC-114887 | MT | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.