Provider Demographics
NPI:1083619209
Name:MALICKI, MARK MITCHELL (MD)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:MITCHELL
Last Name:MALICKI
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:322 WARREN ST
Mailing Address - Street 2:STE 300
Mailing Address - City:JOHNSTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:15905-3443
Mailing Address - Country:US
Mailing Address - Phone:814-288-1418
Mailing Address - Fax:814-288-1525
Practice Address - Street 1:322 WARREN ST
Practice Address - Street 2:STE 300
Practice Address - City:JOHNSTOWN
Practice Address - State:PA
Practice Address - Zip Code:15905-3443
Practice Address - Country:US
Practice Address - Phone:814-288-1418
Practice Address - Fax:814-288-1525
Is Sole Proprietor?:No
Enumeration Date:2005-06-15
Last Update Date:2010-06-17
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
PAMD069004L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0017621130005Medicaid
PA035509Medicare PIN
PAH10519Medicare UPIN