Healthcare Provider Details

I. General information

NPI: 1922095272
Provider Name (Legal Business Name): KRISHNA MALLIK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2005
Last Update Date: 11/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4110 N SCOTTSDALE RD STE 215
SCOTTSDALE AZ
85251-3635
US

IV. Provider business mailing address

7181 E CAMELBACK RD SUITE #303
SCOTTSDALE AZ
85251-1279
US

V. Phone/Fax

Practice location:
  • Phone: 855-804-8800
  • Fax: 480-907-2994
Mailing address:
  • Phone: 855-804-8800
  • Fax: 480-907-2994

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207X00000X
TaxonomyOrthopaedic Surgery Physician
License Number37346
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207XX0005X
TaxonomySports Medicine (Orthopaedic Surgery) Physician
License Number37346
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: