Provider Demographics
NPI:1386930428
Name:MALLICK, NADIR (MD)
Entity type:Individual
Prefix:
First Name:NADIR
Middle Name:
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 1:1040 SIERRA DR
Mailing Address - Street 2:SUITE 400
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-7241
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:20180 S LAGRANGE RD
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IL
Practice Address - Zip Code:60423-3153
Practice Address - Country:US
Practice Address - Phone:815-464-2010
Practice Address - Fax:815-464-2181
Is Sole Proprietor?:No
Enumeration Date:2011-06-28
Last Update Date:2015-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301099249207Q00000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILF400183639OtherMEDICARE PTAN
IL036136607Medicaid