Provider Demographics
NPI:1194731521
Name:MALLIK, GAGAN C (MD)
Entity type:Individual
Prefix:
First Name:GAGAN
Middle Name:C
Last Name:MALLIK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:24651 CENTER RIDGE RD
Mailing Address - Street 2:SUITE 350
Mailing Address - City:WESTLAKE
Mailing Address - State:OH
Mailing Address - Zip Code:44145-5635
Mailing Address - Country:US
Mailing Address - Phone:440-895-5056
Mailing Address - Fax:440-333-2935
Practice Address - Street 1:7575 NORTHCLIFF AVE
Practice Address - Street 2:SUITE 301
Practice Address - City:BROOKLYN
Practice Address - State:OH
Practice Address - Zip Code:44144-3267
Practice Address - Country:US
Practice Address - Phone:216-271-6299
Practice Address - Fax:216-271-6299
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2014-08-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TN41404207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3828540Medicaid
TN3828540Medicaid
TN3828540Medicare ID - Type UnspecifiedINDIVIDUAL #