Provider Demographics
NPI:1568421212
Name:MALLAT, DAMIEN B (MD)
Entity Type:Individual
Prefix:DR
First Name:DAMIEN
Middle Name:B
Last Name:MALLAT
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 1:7777 FOREST LN
Mailing Address - Street 2:C204
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75230-2571
Mailing Address - Country:US
Mailing Address - Phone:972-566-5266
Mailing Address - Fax:972-566-5245
Practice Address - Street 1:7777 FOREST LN
Practice Address - Street 2:BLDG. C SUITE 204
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75230-2571
Practice Address - Country:US
Practice Address - Phone:972-566-5266
Practice Address - Fax:972-566-5245
Is Sole Proprietor?:No
Enumeration Date:2006-03-21
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL0393207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX157312301Medicaid
TX157312303Medicaid
TX157312302Medicaid
TX8A5534OtherBCBSTX
TX157312304Medicaid
TXTXB144367Medicare PIN
TXP00001542Medicare PIN
TX8A5534OtherBCBSTX
TXTXB144371Medicare PIN
TX8A5534Medicare PIN
TX157312301Medicaid