Provider Demographics
NPI:1174856983
Name:MALLISHO, ABDULLAH (MD)
Entity Type:Individual
Prefix:DR
First Name:ABDULLAH
Middle Name:
Last Name:MALLISHO
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:5250 AUTO CLUB DR
Mailing Address - Street 2:STE 200
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48126-4212
Mailing Address - Country:US
Mailing Address - Phone:313-914-5591
Mailing Address - Fax:313-982-9942
Practice Address - Street 1:5250 AUTO CLUB DR
Practice Address - Street 2:STE 200
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-4212
Practice Address - Country:US
Practice Address - Phone:313-914-5591
Practice Address - Fax:313-982-9942
Is Sole Proprietor?:No
Enumeration Date:2009-09-10
Last Update Date:2016-07-19
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MI4301094502207R00000X, 207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI3696005Medicare PIN