Provider Demographics
NPI:1740535004
Name:MALLICK, DEOBRAT CHANDRA (MD)
Entity type:Individual
Prefix:DR
First Name:DEOBRAT
Middle Name:CHANDRA
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 1:205 TALL TREES DR
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18505-2239
Mailing Address - Country:US
Mailing Address - Phone:570-687-7332
Mailing Address - Fax:
Practice Address - Street 1:205 TALL TREES DR
Practice Address - Street 2:
Practice Address - City:SCRANTON
Practice Address - State:PA
Practice Address - Zip Code:18505-2239
Practice Address - Country:US
Practice Address - Phone:570-687-7332
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-23
Last Update Date:2012-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMT200781207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine