Provider Demographics
NPI:1568508976
Name:TILAK K MALLIK MD FACE LLC
Entity Type:Organization
Organization Name:TILAK K MALLIK MD FACE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BAISHALI
Authorized Official - Middle Name:
Authorized Official - Last Name:MALLIK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:504-349-6521
Mailing Address - Street 1:1111 MEDICAL CENTER BLVD
Mailing Address - Street 2:SUITE S113
Mailing Address - City:MARRERO
Mailing Address - State:LA
Mailing Address - Zip Code:70072
Mailing Address - Country:US
Mailing Address - Phone:504-349-6520
Mailing Address - Fax:504-349-6522
Practice Address - Street 1:1111 MEDICAL CENTER BLVD
Practice Address - Street 2:SUITE S113
Practice Address - City:MARRERO
Practice Address - State:LA
Practice Address - Zip Code:70072
Practice Address - Country:US
Practice Address - Phone:504-349-6520
Practice Address - Fax:504-349-6522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA4776R207RE0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & MetabolismGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA0314839001OtherCIGNA
LA1317926Medicaid
LAF6746OtherBC
LAF6746OtherBC
B61272Medicare UPIN