Provider Demographics
NPI:1386633931
Name:MALIK, SHASHI KANTA (MD)
Entity Type:Individual
Prefix:DR
First Name:SHASHI
Middle Name:KANTA
Last Name:MALIK
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 1:2176 FORT ST
Mailing Address - Street 2:
Mailing Address - City:LINCOLN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48146-2405
Mailing Address - Country:US
Mailing Address - Phone:313-381-0713
Mailing Address - Fax:313-381-1977
Practice Address - Street 1:2176 FORT ST
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:MI
Practice Address - Zip Code:48146-2405
Practice Address - Country:US
Practice Address - Phone:313-381-0713
Practice Address - Fax:313-381-1977
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-17
Last Update Date:2010-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISM045356207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0823508Medicare ID - Type Unspecified
MIA73351Medicare UPIN