Provider Demographics
NPI:1962865097
Name:MALLICK, FARYAL J (MD)
Entity type:Individual
Prefix:
First Name:FARYAL
Middle Name:J
Last Name:MALLICK
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10006 CROSS CREEK BLVD STE 124
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33647-2595
Mailing Address - Country:US
Mailing Address - Phone:813-461-7707
Mailing Address - Fax:
Practice Address - Street 1:14003 N DALE MABRY HWY STE C
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33618-2459
Practice Address - Country:US
Practice Address - Phone:813-461-7797
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-05
Last Update Date:2025-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTP9442084P0800X
KY519442084P0800X
390200000X
FLME1401492084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100572460Medicaid