Healthcare Provider Details

I. General information

NPI: 1083619209
Provider Name (Legal Business Name): MARK MITCHELL MALICKI MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2005
Last Update Date: 06/17/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

322 WARREN ST STE 300
JOHNSTOWN PA
15905-3443
US

IV. Provider business mailing address

322 WARREN ST STE 300
JOHNSTOWN PA
15905-3443
US

V. Phone/Fax

Practice location:
  • Phone: 814-288-1418
  • Fax: 814-288-1525
Mailing address:
  • Phone: 814-288-1418
  • Fax: 814-288-1525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberMD069004L
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: