Provider Demographics
NPI:1467529271
Name:ALAM, MALLICK QAISER (MD)
Entity Type:Individual
Prefix:
First Name:MALLICK
Middle Name:QAISER
Last Name:ALAM
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:QAISER
Other - Middle Name:
Other - Last Name:MALLICK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:77 GRAND AVE
Mailing Address - Street 2:
Mailing Address - City:NEW HAVEN
Mailing Address - State:CT
Mailing Address - Zip Code:06513-3906
Mailing Address - Country:US
Mailing Address - Phone:203-562-8697
Mailing Address - Fax:203-562-1822
Practice Address - Street 1:77 GRAND AVE
Practice Address - Street 2:
Practice Address - City:NEW HAVEN
Practice Address - State:CT
Practice Address - Zip Code:06513-3906
Practice Address - Country:US
Practice Address - Phone:203-562-8697
Practice Address - Fax:203-562-1822
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT034112208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
G07321Medicare UPIN