Provider Demographics
NPI:1689607798
Name:MALLICK, MOHAMMAD S (MD)
Entity Type:Individual
Prefix:
First Name:MOHAMMAD
Middle Name:S
Last Name:MALLICK
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 1:1525 LIBERTY CT
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53045-5327
Mailing Address - Country:US
Mailing Address - Phone:262-646-6280
Mailing Address - Fax:
Practice Address - Street 1:1525 LIBERTY CT
Practice Address - Street 2:
Practice Address - City:BROOKFIELD
Practice Address - State:WI
Practice Address - Zip Code:53045-5327
Practice Address - Country:US
Practice Address - Phone:262-646-6280
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-09
Last Update Date:2008-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI277192084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI31466300Medicaid
WI391843015OtherEIN
WI391843015OtherEIN
WI31466300Medicaid