Provider Demographics
NPI:1245536440
Name:SHAHLA MALLICK MEDICAL PC
Entity type:Organization
Organization Name:SHAHLA MALLICK MEDICAL PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHAHLA
Authorized Official - Middle Name:
Authorized Official - Last Name:MALLICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:718-833-7860
Mailing Address - Street 1:208 PARKWAY DR
Mailing Address - Street 2:
Mailing Address - City:ROSLYN HEIGHTS
Mailing Address - State:NY
Mailing Address - Zip Code:11577-2737
Mailing Address - Country:US
Mailing Address - Phone:718-833-7860
Mailing Address - Fax:718-833-7861
Practice Address - Street 1:517 54TH ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11220-3114
Practice Address - Country:US
Practice Address - Phone:718-833-7860
Practice Address - Fax:718-833-7861
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-04
Last Update Date:2024-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY217612261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02106307Medicaid
NYOD3951Medicare UPIN
NY65553Medicare PIN