Basic Information
| Provider Information | |||||||||
| NPI: | 1477580397 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MALLON | ||||||||
| FirstName: | VICTORIA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 310 COLORADO AVE | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 81004 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195438718 | ||||||||
| FaxNumber: | 7195435340 | ||||||||
| Practice Location | |||||||||
| Address1: | 300 COLORADO AVE | ||||||||
| Address2: | |||||||||
| City: | PUEBLO | ||||||||
| State: | CO | ||||||||
| PostalCode: | 810042006 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7195438711 | ||||||||
| FaxNumber: | 7195435340 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2006 | ||||||||
| LastUpdateDate: | 02/24/2010 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 39730 | CO | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 20631561 | 05 | CO | MEDICAID |