MEDICARE: DR. TAYMOUR EDWARD MALAK M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	A400760	CA
2	208D00000X	General Practice Physician	A400760	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	A40076	OTHER	CA	STATE LICENSE NUMBER
3	680045304	OTHER	CA	TAX IDENTIFICATION NUMBER

General Provider Information

NPI Number	:	1104931260
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. TAYMOUR EDWARD MALAK M.D.

Provider Business Mailing Address
First Line	:	2800 N CALIFORNIA ST STE 11
Second Line	:	2800 N. CALIFORNIA STREET SUITE 11
City	:	STOCKTON
State	:	CA
Zip	:	95204-3758
Country	:	US
Telephone Number	:	209-465-5891
Fax Number	:	209-465-0008

Provider Business Practice Location Address
First Line	:	2800 N CALIFORNIA ST STE 11
Second Line	:	2800 N. CALIFORNIA STREET SUITE 11
City	:	STOCKTON
State	:	CA
Zip	:	95204-3758
Country	:	US
Telephone Number	:	209-465-5891
Fax Number	:	209-465-0008

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/20/2006
Last Update Date	:	02/17/2012

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