Provider Demographics
NPI:1215943832
Name:MALLICK, IMTIAZ A (MD)
Entity type:Individual
Prefix:
First Name:IMTIAZ
Middle Name:A
Last Name:MALLICK
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 1:798 ROUTE 9
Mailing Address - Street 2:
Mailing Address - City:FISHKILL
Mailing Address - State:NY
Mailing Address - Zip Code:12524-1393
Mailing Address - Country:US
Mailing Address - Phone:845-896-2204
Mailing Address - Fax:845-896-5173
Practice Address - Street 1:798 ROUTE 9
Practice Address - Street 2:
Practice Address - City:FISHKILL
Practice Address - State:NY
Practice Address - Zip Code:12524-1393
Practice Address - Country:US
Practice Address - Phone:845-896-2204
Practice Address - Fax:845-896-5173
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2022-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY196451207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01485712Medicaid
NY141777521OtherTAX ID NUMBER
NYF87104Medicare UPIN
NY93H111Medicare PIN