Provider Demographics
NPI:1790813863
Name:MALLICO, ERIC JOHN (MD)
Entity Type:Individual
Prefix:DR
First Name:ERIC
Middle Name:JOHN
Last Name:MALLICO
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1910 JAKE ALEXANDER BLVD W STE 201
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28147-1165
Practice Address - Country:US
Practice Address - Phone:704-638-8631
Practice Address - Fax:704-638-8639
Is Sole Proprietor?:No
Enumeration Date:2007-03-01
Last Update Date:2022-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2008-01430208600000X
NC116331208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5910179Medicaid
NC1511EOtherBCBS
NC2022876Medicare PIN