Healthcare Provider Details

I. General information

NPI: 1427615665
Provider Name (Legal Business Name): DR. ALI IMRAN MALLICK
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2019
Last Update Date: 09/16/2025
Certification Date: 09/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 BARD AVE DEPARTMENT OF PSYCHIATRY, 1ST FLOOR
STATEN ISLAND NY
10310
US

IV. Provider business mailing address

7534 193RD ST
FRESH MEADOWS NY
11366-1834
US

V. Phone/Fax

Practice location:
  • Phone: 718-818-4121
  • Fax:
Mailing address:
  • Phone: 917-650-9930
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number320321
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number320321
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: