Provider Demographics
NPI:1407949621
Name:MALLOUK, ABDELKADER (MD, OD)
Entity Type:Individual
Prefix:MR
First Name:ABDELKADER
Middle Name:
Last Name:MALLOUK
Suffix:
Gender:M
Credentials:MD, OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:571 SAINT JOSEPHS BLVD FL 2
Mailing Address - Street 2:
Mailing Address - City:ELMIRA
Mailing Address - State:NY
Mailing Address - Zip Code:14901-3230
Mailing Address - Country:US
Mailing Address - Phone:607-271-2050
Mailing Address - Fax:
Practice Address - Street 1:100 JOHN ROEMMELT DR STE 302
Practice Address - Street 2:
Practice Address - City:HORSEHEADS
Practice Address - State:NY
Practice Address - Zip Code:14845-8304
Practice Address - Country:US
Practice Address - Phone:607-873-1810
Practice Address - Fax:607-562-3157
Is Sole Proprietor?:No
Enumeration Date:2006-10-02
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC3141152W00000X
NYT005983152W00000X
PAOE8142152W00000X
NY277295207QA0401X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No152W00000XEye and Vision Services ProvidersOptometrist
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01916898Medicaid
NYJ400182631Medicare PIN
U69228Medicare UPIN