Provider Demographics
NPI:1215355474
Name:MALLICK, JAYATI (MD)
Entity Type:Individual
Prefix:
First Name:JAYATI
Middle Name:
Last Name:MALLICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 650859 DEPT 710
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75265-6234
Mailing Address - Country:US
Mailing Address - Phone:409-772-0620
Mailing Address - Fax:
Practice Address - Street 1:301 UNIVERSITY BLVD
Practice Address - Street 2:
Practice Address - City:GALVESTON
Practice Address - State:TX
Practice Address - Zip Code:77555-0001
Practice Address - Country:US
Practice Address - Phone:409-772-2222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-03
Last Update Date:2023-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXS5008207ZP0102X, 207ZH0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207ZH0000XAllopathic & Osteopathic PhysiciansPathologyHematologyGroup - Multi-Specialty
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical PathologyGroup - Multi-Specialty