Healthcare Provider Details

I. General information

NPI: 1932729662
Provider Name (Legal Business Name): BENJAMIN MALLICOAT MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2020
Last Update Date: 08/19/2024
Certification Date: 08/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5955 ZEAMER AVE
ANCHORAGE AK
99506-3702
US

IV. Provider business mailing address

5955 ZEAMER AVE
ANCHORAGE AK
99506-3702
US

V. Phone/Fax

Practice location:
  • Phone: 937-208-2007
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number01089128A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: