Basic Information
| Provider Information | |||||||||
| NPI: | 1831139039 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MALLORY | ||||||||
| FirstName: | DOROTHY | ||||||||
| MiddleName: | JILL | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 251 E COTTAGE GROVE RD | ||||||||
| Address2: | |||||||||
| City: | COTTAGE GROVE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535279619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6088393515 | ||||||||
| FaxNumber: | 6088393541 | ||||||||
| Practice Location | |||||||||
| Address1: | 251 E COTTAGE GROVE RD | ||||||||
| Address2: | |||||||||
| City: | COTTAGE GROVE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 535279619 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6088393515 | ||||||||
| FaxNumber: | 6088393541 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2006 | ||||||||
| LastUpdateDate: | 11/02/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 49462-020 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 34734300 | 05 | WI | MEDICAID | 151150020 | 01 | WI | MEDICARE PTAN | OTHER |