Provider Demographics
NPI:1366496119
Name:HERMINA, MALAK GADALLA (MD FACP)
Entity Type:Individual
Prefix:DR
First Name:MALAK
Middle Name:GADALLA
Last Name:HERMINA
Suffix:
Gender:M
Credentials:MD FACP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5525 GEORGETOWN RD STE F
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46254-3717
Mailing Address - Country:US
Mailing Address - Phone:317-293-9039
Mailing Address - Fax:317-293-9049
Practice Address - Street 1:5525 GEORGETOWN RD SUITE F
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46254
Practice Address - Country:US
Practice Address - Phone:317-293-9039
Practice Address - Fax:317-293-9049
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2017-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN0104871207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
ININ3178001Medicare PIN
H56185Medicare UPIN