Provider Demographics
NPI:1023209897
Name:MALIK, LYNETTE SANTOS (MD)
Entity Type:Individual
Prefix:DR
First Name:LYNETTE
Middle Name:SANTOS
Last Name:MALIK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LYNETTE
Other - Middle Name:REPASO
Other - Last Name:SANTOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3600 N INTERSTATE AVE
Mailing Address - Street 2:DEPARTMENT OF PHYSICAL MEDICINE
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97227-1106
Mailing Address - Country:US
Mailing Address - Phone:503-331-3070
Mailing Address - Fax:503-331-3089
Practice Address - Street 1:3600 N INTERSTATE AVE
Practice Address - Street 2:DEPARTMENT OF PHYSICAL MEDICINE
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97227-1106
Practice Address - Country:US
Practice Address - Phone:503-331-3070
Practice Address - Fax:503-331-3089
Is Sole Proprietor?:No
Enumeration Date:2007-08-07
Last Update Date:2013-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL125053433208100000X
MO2011033713208100000X
ORMD1631172081S0010X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
No208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO151850004Medicare PIN