Healthcare Provider Details

I. General information

NPI: 1801884523
Provider Name (Legal Business Name): SUDHIR MALIK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2005
Last Update Date: 11/18/2020
Certification Date: 11/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4033 3RD AVE STE 420
SAN DIEGO CA
92103-2140
US

IV. Provider business mailing address

PO BOX 2702
WEIRTON WV
26062-1902
US

V. Phone/Fax

Practice location:
  • Phone: 619-294-9292
  • Fax: 619-294-3311
Mailing address:
  • Phone: 740-282-6390
  • Fax: 740-266-7749

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number35057785
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License NumberC54773
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2084N0402X
TaxonomyNeurology with Special Qualifications in Child Neurology Physician
License NumberC54773
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code2084N0600X
TaxonomyClinical Neurophysiology Physician
License NumberC54773
License Number StateCA
# 5
Primary TaxonomyN
Taxonomy Code2084S0012X
TaxonomySleep Medicine (Psychiatry & Neurology) Physician
License Number35057785
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: