Healthcare Provider Details

I. General information

NPI: 1467773028
Provider Name (Legal Business Name): LAWRENCE TAYMOUR MALAK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/17/2010
Last Update Date: 10/23/2024
Certification Date: 10/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3350 LA JOLLA VILLAGE DR DEPT OF PSYCHIATRY - 116A
SAN DIEGO CA
92161-0002
US

IV. Provider business mailing address

PO BOX 232410
SAN DIEGO CA
92193-2410
US

V. Phone/Fax

Practice location:
  • Phone: 858-534-4040
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA115345
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: