Provider Demographics
NPI:1952523219
Name:MALLICK, KIM SHANNON (MD)
Entity Type:Individual
Prefix:DR
First Name:KIM
Middle Name:SHANNON
Last Name:MALLICK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:1221 MADISON ST
Mailing Address - Street 2:SUITE 1218
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98104-1356
Mailing Address - Country:US
Mailing Address - Phone:206-215-2323
Mailing Address - Fax:206-215-2320
Practice Address - Street 1:1221 MADISON ST
Practice Address - Street 2:SUITE 1218
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98104-1356
Practice Address - Country:US
Practice Address - Phone:206-215-2323
Practice Address - Fax:206-215-2320
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
WAMD00027008207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA32114OtherLABOR AND INDUSTRIES
WA1078542Medicaid
WA1078542Medicaid