Provider Demographics
NPI:1770687873
Name:GAGAN C MALLIK MD INC
Entity type:Organization
Organization Name:GAGAN C MALLIK MD INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GAGAN
Authorized Official - Middle Name:C
Authorized Official - Last Name:MALLIK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:216-406-7268
Mailing Address - Street 1:5162 BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44127-1571
Mailing Address - Country:US
Mailing Address - Phone:216-406-7268
Mailing Address - Fax:
Practice Address - Street 1:5162 BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44127-1571
Practice Address - Country:US
Practice Address - Phone:216-406-7268
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-11
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN41404207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3735527Medicaid
TN3735527Medicaid
TN3735527Medicare ID - Type UnspecifiedTN MEDICARE GRP #