Provider Demographics
NPI:1376527663
Name:MALLIK, GUNWANT S (MD)
Entity Type:Individual
Prefix:
First Name:GUNWANT
Middle Name:S
Last Name:MALLIK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 712844
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45271-0001
Mailing Address - Country:US
Mailing Address - Phone:614-942-0132
Mailing Address - Fax:614-942-0139
Practice Address - Street 1:450 ALKYRE RUN
Practice Address - Street 2:SUITE 300
Practice Address - City:WESTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:43082-6909
Practice Address - Country:US
Practice Address - Phone:614-942-0132
Practice Address - Fax:614-942-0139
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-01
Last Update Date:2015-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35070094207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH208005968026OtherCARESOURCE
OH000000518235OtherBLUE CROSS/BLUE SHIELD
OH208005968OtherCIGNA
OH208005968OtherUNITED HEALTHCARE
OH208005968OtherTRICARE NORTH REGION
OH208005968OtherAETNA
OH0225723Medicaid
OH208005968OtherCIGNA
OH208005968OtherUNITED HEALTHCARE
OHE26966Medicare UPIN