Healthcare Provider Details

I. General information

NPI: 1104998798
Provider Name (Legal Business Name): NUSRAT MALIK M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 10/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1501 CLAUS RD DBHC
MODESTO CA
95355-9711
US

IV. Provider business mailing address

3113 JOLIE PRE CIR
MODESTO CA
95356-9315
US

V. Phone/Fax

Practice location:
  • Phone: 209-557-6300
  • Fax:
Mailing address:
  • Phone: 209-545-6969
  • Fax: 209-545-3391

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA54022
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: