Provider Demographics
NPI:1134533102
Name:MALLARD, CHRISTOPHER (MD)
Entity type:Individual
Prefix:DR
First Name:CHRISTOPHER
Middle Name:
Last Name:MALLARD
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5710 OLEANDER DR STE 201
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28403-4722
Mailing Address - Country:US
Mailing Address - Phone:333-657-2468
Mailing Address - Fax:910-338-0909
Practice Address - Street 1:2400 GREATSTONE PT STE A100
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40504-3274
Practice Address - Country:US
Practice Address - Phone:859-323-7246
Practice Address - Fax:859-257-6768
Is Sole Proprietor?:No
Enumeration Date:2014-06-17
Last Update Date:2022-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY51522207L00000X, 208VP0014X, 207LP2900X
KYR3550207L00000X
SC83081208VP0014X
NC2019-00963208VP0014X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
No207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100367930Medicaid