Provider Demographics
NPI:1154320984
Name:MALIK, AYAZ TARIQ (MD)
Entity Type:Individual
Prefix:
First Name:AYAZ
Middle Name:TARIQ
Last Name:MALIK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:A.
Other - Middle Name:TARIQ
Other - Last Name:MALIK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:250 GREEN ST
Mailing Address - Street 2:STE 212
Mailing Address - City:GARDNER
Mailing Address - State:MA
Mailing Address - Zip Code:01440-1396
Mailing Address - Country:US
Mailing Address - Phone:978-669-5522
Mailing Address - Fax:978-632-0516
Practice Address - Street 1:250 GREEN ST
Practice Address - Street 2:STE 212
Practice Address - City:GARDNER
Practice Address - State:MA
Practice Address - Zip Code:01440-1396
Practice Address - Country:US
Practice Address - Phone:978-669-5522
Practice Address - Fax:978-632-0516
Is Sole Proprietor?:No
Enumeration Date:2005-07-14
Last Update Date:2011-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA33591207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA0154695Medicaid
MA0154695Medicaid
MABX0432Medicare PIN