Provider Demographics
NPI:1053730960
Name:LARA, MALLORY ANNE (MD)
Entity type:Individual
Prefix:
First Name:MALLORY
Middle Name:ANNE
Last Name:LARA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MALLORY
Other - Middle Name:A
Other - Last Name:DUNCAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 742712
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-2712
Mailing Address - Country:US
Mailing Address - Phone:877-866-7123
Mailing Address - Fax:
Practice Address - Street 1:17218 PRESTON RD STE 2000
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75252-4018
Practice Address - Country:US
Practice Address - Phone:877-866-7123
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-08
Last Update Date:2023-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS3545208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX404654203Medicaid