Provider Demographics
NPI:1578033254
Name:MALAICKAL, NIBU JACOB (REEGT, RPSGT,RNCST)
Entity Type:Individual
Prefix:
First Name:NIBU
Middle Name:JACOB
Last Name:MALAICKAL
Suffix:
Gender:M
Credentials:REEGT, RPSGT,RNCST
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 S COPPELL RD
Mailing Address - Street 2:
Mailing Address - City:COPPELL
Mailing Address - State:TX
Mailing Address - Zip Code:75019-2417
Mailing Address - Country:US
Mailing Address - Phone:214-686-9393
Mailing Address - Fax:
Practice Address - Street 1:304 S COPPELL RD
Practice Address - Street 2:
Practice Address - City:COPPELL
Practice Address - State:TX
Practice Address - Zip Code:75019-2417
Practice Address - Country:US
Practice Address - Phone:214-686-9393
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-26
Last Update Date:2018-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
138273100000X
4499246ZE0500X
878246ZE0600X
16863261QS1200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes246ZE0500XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherEEG
No273100000XHospital UnitsEpilepsy Unit
No246ZE0600XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, OtherElectroneurodiagnostic
No261QS1200XAmbulatory Health Care FacilitiesClinic/CenterSleep Disorder Diagnostic