Provider Demographics
NPI:1437597366
Name:MALLICK, ADNAN M (MD)
Entity Type:Individual
Prefix:DR
First Name:ADNAN
Middle Name:M
Last Name:MALLICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1 CORPORATE DR
Mailing Address - Street 2:
Mailing Address - City:WAYNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07470-3112
Mailing Address - Country:US
Mailing Address - Phone:973-987-3380
Mailing Address - Fax:866-806-3675
Practice Address - Street 1:1255 BROAD ST STE 104
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:NJ
Practice Address - Zip Code:07003-3061
Practice Address - Country:US
Practice Address - Phone:973-707-5632
Practice Address - Fax:973-707-7349
Is Sole Proprietor?:No
Enumeration Date:2013-06-13
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY277002207WX0107X
NJ25MA10886200207WX0107X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0230917Medicaid