MEDICARE: ABDUL MALIK PHYSICIAN PC

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	261QH0100X	Health Service Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	A100045528	OTHER	NY	PTAN

General Provider Information

NPI Number	:	1699901561
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ABDUL MALIK PHYSICIAN PC

Provider Business Mailing Address
First Line	:	1 VILLADOM CT
Second Line	:
City	:	DIX HILLS
State	:	NY
Zip	:	11746-5444
Country	:	US
Telephone Number	:	718-469-4006
Fax Number	:

Provider Business Practice Location Address
First Line	:	1 VILLADOM CT
Second Line	:
City	:	DIX HILLS
State	:	NY
Zip	:	11746-5444
Country	:	US
Telephone Number	:	718-469-4006
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	DR. ABDUL MALIK
Credential	:	M.D.
Telephone Number	:	718-469-4006

Provider Enumeration Date	:	06/05/2009
Last Update Date	:	05/19/2011

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