Provider Demographics
NPI:1396738415
Name:MALLICK, SHAHID Q (MD)
Entity type:Individual
Prefix:DR
First Name:SHAHID
Middle Name:Q
Last Name:MALLICK
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 1:3511 TOWN CENTER BLVD S
Mailing Address - Street 2:SUITE #102
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77479-1285
Mailing Address - Country:US
Mailing Address - Phone:281-491-1185
Mailing Address - Fax:281-491-1247
Practice Address - Street 1:3511 TOWN CENTER BLVD S
Practice Address - Street 2:SUITE #102
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77479-1285
Practice Address - Country:US
Practice Address - Phone:281-491-1185
Practice Address - Fax:281-491-1247
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-24
Last Update Date:2007-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXJ8042207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX122372903Medicaid
TXG00247Medicare UPIN
TX00895JMedicare ID - Type Unspecified