Healthcare Provider Details

I. General information

NPI: 1083946792
Provider Name (Legal Business Name): IMTIAZ A. MALLICK PHYSICIAN P.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/04/2010
Last Update Date: 03/05/2022
Certification Date: 03/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

798 ROUTE 9
FISHKILL NY
12524-1393
US

IV. Provider business mailing address

798 ROUTE 9
FISHKILL NY
12524-1393
US

V. Phone/Fax

Practice location:
  • Phone: 845-896-2204
  • Fax: 845-896-5173
Mailing address:
  • Phone: 845-896-2204
  • Fax: 845-896-5173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number196451
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: IMTIAZ A MALLICK
Title or Position: PRESIDENT & CEO
Credential: M.D.
Phone: 845-896-2204