Provider Demographics
NPI:1508025594
Name:MALIK, AWAIS (MD)
Entity Type:Individual
Prefix:DR
First Name:AWAIS
Middle Name:
Last Name:MALIK
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 1:754 CLINTON AVE
Mailing Address - Street 2:
Mailing Address - City:BRIDGEPORT
Mailing Address - State:CT
Mailing Address - Zip Code:06604-2301
Mailing Address - Country:US
Mailing Address - Phone:203-923-2204
Mailing Address - Fax:203-923-2205
Practice Address - Street 1:754 CLINTON AVE
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:CT
Practice Address - Zip Code:06604-2301
Practice Address - Country:US
Practice Address - Phone:203-923-2204
Practice Address - Fax:203-923-2205
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-04
Last Update Date:2020-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT049851207QA0505X, 208D00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT008059397Medicaid