Provider Demographics
NPI:1629583596
Name:MALAK, CHARLES (NP)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:MALAK
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:325 DISTEL CIR
Mailing Address - Street 2:
Mailing Address - City:LOS ALTOS
Mailing Address - State:CA
Mailing Address - Zip Code:94022-1408
Mailing Address - Country:US
Mailing Address - Phone:650-853-2943
Mailing Address - Fax:
Practice Address - Street 1:795 EL CAMINO REAL
Practice Address - Street 2:
Practice Address - City:PALO ALTO
Practice Address - State:CA
Practice Address - Zip Code:94301
Practice Address - Country:US
Practice Address - Phone:650-853-2943
Practice Address - Fax:650-853-6094
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-13
Last Update Date:2020-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95006648363LF0000X
CA553346363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty