Provider Demographics
NPI:1992800106
Name:AMIR A MALIK MD PA
Entity type:Organization
Organization Name:AMIR A MALIK MD PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:AMIR
Authorized Official - Middle Name:A
Authorized Official - Last Name:MALIK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:904-829-8300
Mailing Address - Street 1:PO BOX 1779
Mailing Address - Street 2:
Mailing Address - City:ST AUGUSTINE
Mailing Address - State:FL
Mailing Address - Zip Code:32085-1779
Mailing Address - Country:US
Mailing Address - Phone:904-824-4990
Mailing Address - Fax:904-824-2226
Practice Address - Street 1:204 SOUTHPARK CIR E
Practice Address - Street 2:
Practice Address - City:ST AUGUSTINE
Practice Address - State:FL
Practice Address - Zip Code:32086-5135
Practice Address - Country:US
Practice Address - Phone:904-829-8300
Practice Address - Fax:904-829-8310
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-13
Last Update Date:2010-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL273954200Medicaid
FLCJ9642OtherRAILROAD MEDICARE
FL273954200Medicaid