Provider Demographics
NPI:1437160959
Name:MALLIK, TILAK KUMAR (MD)
Entity Type:Individual
Prefix:
First Name:TILAK
Middle Name:KUMAR
Last Name:MALLIK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1111 MEDICAL CENTER BLVD
Mailing Address - Street 2:SUITE S113
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072-3151
Mailing Address - Country:US
Mailing Address - Phone:504-349-6520
Mailing Address - Fax:504-349-6522
Practice Address - Street 1:1111 MEDICAL CENTER BLVD
Practice Address - Street 2:SUITE S 113
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072-3151
Practice Address - Country:US
Practice Address - Phone:504-349-6520
Practice Address - Fax:504-349-6522
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2018-03-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
LA04776R207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA1317926Medicaid
LA1317926Medicaid
B61272Medicare UPIN