Provider Demographics
NPI:1073559159
Name:JOSEPH, DOMINIC MALIAKKAL (MDPA)
Entity Type:Individual
Prefix:DR
First Name:DOMINIC
Middle Name:MALIAKKAL
Last Name:JOSEPH
Suffix:
Gender:M
Credentials:MDPA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2026 VALLERIA CT
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77479-5568
Mailing Address - Country:US
Mailing Address - Phone:281-265-8056
Mailing Address - Fax:
Practice Address - Street 1:9401 SOUTHWEST FWY
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77074-1407
Practice Address - Country:US
Practice Address - Phone:713-970-3354
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-20
Last Update Date:2020-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ12782084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX131226606Medicaid
TX131226605Medicaid
TX260044914OtherRAIL ROAD
TX131226604Medicaid
TX260044915OtherRAIL ROAD
TX89406SOtherBLUE CROSS BLUE SHIELD