Healthcare Provider Details

I. General information

NPI: 1275820359
Provider Name (Legal Business Name): JOSEPH GEORGE MALIAKKAL M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/08/2011
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 S GRAND BLVD
ST. LOUIS MO
63104-1003
US

IV. Provider business mailing address

3691 RUTGER AVE
ST. LOUIS MO
63110-2515
US

V. Phone/Fax

Practice location:
  • Phone: 314-268-4101
  • Fax: 314-577-5379
Mailing address:
  • Phone: 314-977-6828
  • Fax: 314-977-6872

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2017018898
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: