Healthcare Provider Details

I. General information

NPI: 1497723878
Provider Name (Legal Business Name): JOSEPH MALAK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2006
Last Update Date: 12/24/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 WASHINGTON ST SUITE 103
POUGHKEEPSIE NY
12601-8111
US

IV. Provider business mailing address

207 WASHINGTON ST SUITE 103
POUGHKEEPSIE NY
12601-8111
US

V. Phone/Fax

Practice location:
  • Phone: 845-249-2510
  • Fax: 845-249-2505
Mailing address:
  • Phone: 845-249-2510
  • Fax: 845-249-2505

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License Number1593591
License Number StateNY

VII. Legacy identifiers

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

# 1
Identifier01160503
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: