Provider Demographics
NPI:1427615665
Name:MALLICK, ALI IMRAN
Entity type:Individual
Prefix:DR
First Name:ALI
Middle Name:IMRAN
Last Name:MALLICK
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7534 193RD ST
Mailing Address - Street 2:
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11366-1834
Mailing Address - Country:US
Mailing Address - Phone:917-650-9930
Mailing Address - Fax:
Practice Address - Street 1:355 BARD AVE
Practice Address - Street 2:DEPARTMENT OF PSYCHIATRY, 1ST FLOOR
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10310
Practice Address - Country:US
Practice Address - Phone:718-818-4121
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-23
Last Update Date:2019-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program