Provider Demographics
NPI:1386656825
Name:MALLITZ, MICHELLE P (MD)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:P
Last Name:MALLITZ
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5520 PARK AVE
Mailing Address - Street 2:101
Mailing Address - City:TRUMBULL
Mailing Address - State:CT
Mailing Address - Zip Code:06611-3463
Mailing Address - Country:US
Mailing Address - Phone:203-371-5873
Mailing Address - Fax:203-371-5874
Practice Address - Street 1:5520 PARK AVE
Practice Address - Street 2:101
Practice Address - City:TRUMBULL
Practice Address - State:CT
Practice Address - Zip Code:06611-3463
Practice Address - Country:US
Practice Address - Phone:203-371-5873
Practice Address - Fax:203-371-5874
Is Sole Proprietor?:No
Enumeration Date:2006-08-13
Last Update Date:2013-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT042937207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT001429374Medicaid
CT001429374Medicaid
CT110009507Medicare ID - Type Unspecified