Provider Demographics
NPI:1881606846
Name:MALLARD INPATIENT PHYSICIANS
Entity type:Organization
Organization Name:MALLARD INPATIENT PHYSICIANS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:DR
Authorized Official - First Name:ANGEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ISCOVICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:214-712-2403
Mailing Address - Street 1:PO BOX 41766
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19101-1766
Mailing Address - Country:US
Mailing Address - Phone:214-712-2403
Mailing Address - Fax:214-712-2444
Practice Address - Street 1:975 S FAIRMONT AVE
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-5118
Practice Address - Country:US
Practice Address - Phone:309-334-3411
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-11
Last Update Date:2008-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
N/A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA=========OtherCALIFORNIA BLUE CROSS
CA=========OtherTRIWEST
CA=========OtherTRIWEST