Healthcare Provider Details

I. General information

NPI: 1386749505
Provider Name (Legal Business Name): AMIR A MALIK MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/13/2006
Last Update Date: 08/05/2020
Certification Date: 08/05/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 SOUTHPARK CIR E
ST AUGUSTINE FL
32086-5135
US

IV. Provider business mailing address

PO BOX 1779
ST AUGUSTINE FL
32085-1779
US

V. Phone/Fax

Practice location:
  • Phone: 904-829-8300
  • Fax: 904-829-8310
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberME50791
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberME50791
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: