Healthcare Provider Details

I. General information

NPI: 1881787497
Provider Name (Legal Business Name): SUBODH K MALLIK, MD, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2006
Last Update Date: 11/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2071 N MAIN ST
FORT STOCKTON TX
79735-3041
US

IV. Provider business mailing address

2071 N MAIN ST
FORT STOCKTON TX
79735-3041
US

V. Phone/Fax

Practice location:
  • Phone: 432-336-0700
  • Fax: 432-336-0704
Mailing address:
  • Phone: 432-336-0700
  • Fax: 432-336-0704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: SUBODH K MALLIK
Title or Position: OWNER
Credential: MD
Phone: 432-336-0700