Provider Demographics
NPI:1023096708
Name:MOMIN, MALIK (MD)
Entity type:Individual
Prefix:
First Name:MALIK
Middle Name:
Last Name:MOMIN
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 1:825 SIR THOMAS CT
Mailing Address - Street 2:SUITE B
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17109-4839
Mailing Address - Country:US
Mailing Address - Phone:717-652-8670
Mailing Address - Fax:717-901-5009
Practice Address - Street 1:825 SIR THOMAS CT
Practice Address - Street 2:SUITE B
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17109-4839
Practice Address - Country:US
Practice Address - Phone:717-652-8670
Practice Address - Fax:717-901-5009
Is Sole Proprietor?:No
Enumeration Date:2006-01-04
Last Update Date:2010-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD044639-E207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA01236377Medicaid
PA01236377Medicaid
PA664363Medicare ID - Type Unspecified