Provider Demographics
NPI:1689628885
Name:MALLIK, SUBODH K (MD)
Entity Type:Individual
Prefix:
First Name:SUBODH
Middle Name:K
Last Name:MALLIK
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 1:387 W IH 10
Mailing Address - Street 2:
Mailing Address - City:FORT STOCKTON
Mailing Address - State:TX
Mailing Address - Zip Code:79735-2700
Mailing Address - Country:US
Mailing Address - Phone:432-336-0700
Mailing Address - Fax:432-336-0704
Practice Address - Street 1:387 W IH 10
Practice Address - Street 2:
Practice Address - City:FORT STOCKTON
Practice Address - State:TX
Practice Address - Zip Code:79735-2700
Practice Address - Country:US
Practice Address - Phone:432-336-0700
Practice Address - Fax:432-336-0704
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-20
Last Update Date:2013-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK4945207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX111902608Medicaid
TX273470YL08Medicare Oscar/Certification
TXG81147Medicare UPIN
00371MMedicare PIN