Provider Demographics
NPI:1477847234
Name:SUBODH K MALLIK MD PA
Entity Type:Organization
Organization Name:SUBODH K MALLIK MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR./OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUBODH
Authorized Official - Middle Name:
Authorized Official - Last Name:MALLIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:432-336-0700
Mailing Address - Street 1:2071 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:FORT STOCKTON
Mailing Address - State:TX
Mailing Address - Zip Code:79735-3041
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2071 N MAIN ST
Practice Address - Street 2:
Practice Address - City:FORT STOCKTON
Practice Address - State:TX
Practice Address - Zip Code:79735-3041
Practice Address - Country:US
Practice Address - Phone:432-336-0700
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-06-08
Last Update Date:2011-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health