Provider Demographics
NPI:1710148028
Name:MAHALAK, BRIAN W (OD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:W
Last Name:MAHALAK
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 STATE FARM PKWY
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35209-7181
Mailing Address - Country:US
Mailing Address - Phone:205-943-4600
Mailing Address - Fax:205-943-4688
Practice Address - Street 1:461 COTTON GIN RD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36117-3558
Practice Address - Country:US
Practice Address - Phone:334-323-3610
Practice Address - Fax:334-323-3629
Is Sole Proprietor?:No
Enumeration Date:2008-06-19
Last Update Date:2009-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALT-194-TA-783152W00000X
ALS-B98-TA-783152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL515-99302OtherBC
AL1619923745Medicaid
AL1619923745Medicaid