Provider Demographics
NPI:1922095272
Name:MALLIK, KRISHNA (MD)
Entity Type:Individual
Prefix:DR
First Name:KRISHNA
Middle Name:
Last Name:MALLIK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7181 E CAMELBACK RD
Mailing Address - Street 2:SUITE #303
Mailing Address - City:SCOTTSDALE
Mailing Address - State:AZ
Mailing Address - Zip Code:85251-1279
Mailing Address - Country:US
Mailing Address - Phone:855-804-8800
Mailing Address - Fax:480-907-2994
Practice Address - Street 1:4110 N SCOTTSDALE RD STE 215
Practice Address - Street 2:
Practice Address - City:SCOTTSDALE
Practice Address - State:AZ
Practice Address - Zip Code:85251-3635
Practice Address - Country:US
Practice Address - Phone:855-804-8800
Practice Address - Fax:480-907-2994
Is Sole Proprietor?:Yes
Enumeration Date:2005-10-03
Last Update Date:2018-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ37346207X00000X, 207XX0005X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
No207XX0005XAllopathic & Osteopathic PhysiciansOrthopaedic SurgerySports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ152366OtherMEDICARE PTAN
AZ252084Medicaid