Provider Demographics
NPI:1497730816
Name:MALIAKKAL, MAMMEN (MD)
Entity Type:Individual
Prefix:DR
First Name:MAMMEN
Middle Name:
Last Name:MALIAKKAL
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11511 SHADOW CREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:PEARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:77584-7298
Mailing Address - Country:US
Mailing Address - Phone:713-442-4997
Mailing Address - Fax:
Practice Address - Street 1:3333 N FOSTER MALDONADO BLVD
Practice Address - Street 2:
Practice Address - City:EAGLE PASS
Practice Address - State:TX
Practice Address - Zip Code:78852-5893
Practice Address - Country:US
Practice Address - Phone:830-773-5321
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-08
Last Update Date:2021-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXN7455207R00000X, 208M00000X
FLME93011208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLN371170OtherWELLCARE
FL14025OtherBLUE CROSS BLUE SHIELD
FL278190500Medicaid
FL14025OtherBLUE CROSS BLUE SHIELD
FLI34674Medicare UPIN