Healthcare Provider Details

I. General information

NPI: 1376577908
Provider Name (Legal Business Name): JEFFREY TARIQ MALIK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/10/2006
Last Update Date: 11/08/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1212 PLEASANT ST SUITE #LL3
DES MOINES IA
50309-1414
US

IV. Provider business mailing address

1212 PLEASANT ST SUITE #LL3
DES MOINES IA
50309-1414
US

V. Phone/Fax

Practice location:
  • Phone: 515-240-6160
  • Fax:
Mailing address:
  • Phone: 515-240-6160
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number15593
License Number StateHI
# 2
Primary TaxonomyY
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License Number40247
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: