Provider Demographics
NPI:1104931260
Name:MALAK, TAYMOUR EDWARD (MD)
Entity type:Individual
Prefix:DR
First Name:TAYMOUR
Middle Name:EDWARD
Last Name:MALAK
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 1:2800 N CALIFORNIA ST STE 11
Mailing Address - Street 2:2800 N. CALIFORNIA STREET SUITE 11
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95204-3758
Mailing Address - Country:US
Mailing Address - Phone:209-465-5891
Mailing Address - Fax:209-465-0008
Practice Address - Street 1:2800 N CALIFORNIA ST STE 11
Practice Address - Street 2:2800 N. CALIFORNIA STREET SUITE 11
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95204-3758
Practice Address - Country:US
Practice Address - Phone:209-465-5891
Practice Address - Fax:209-465-0008
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-20
Last Update Date:2012-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA400760207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A4007607Medicaid
CAA40076OtherSTATE LICENSE NUMBER
CA680045304OtherTAX IDENTIFICATION NUMBER
CA00A4007607Medicaid
CAA40076OtherSTATE LICENSE NUMBER