Provider Demographics
NPI:1245454693
Name:MOULIK, SUPRATIK KUMAR (MD)
Entity type:Individual
Prefix:DR
First Name:SUPRATIK
Middle Name:KUMAR
Last Name:MOULIK
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 1:1706 PEBBLESTONE CT
Mailing Address - Street 2:
Mailing Address - City:MISSOURI CITY
Mailing Address - State:TX
Mailing Address - Zip Code:77459-1617
Mailing Address - Country:US
Mailing Address - Phone:512-680-7346
Mailing Address - Fax:
Practice Address - Street 1:1706 PEBBLESTONE CT
Practice Address - Street 2:
Practice Address - City:MISSOURI CITY
Practice Address - State:TX
Practice Address - Zip Code:77459-1617
Practice Address - Country:US
Practice Address - Phone:512-680-7346
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-04-13
Last Update Date:2011-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD4383432085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology