Healthcare Provider Details

I. General information

NPI: 1467599613
Provider Name (Legal Business Name): ROBERT J MAMLOK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2007
Last Update Date: 06/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5424 19TH ST SUITE #300
LUBBOCK TX
79407-2162
US

IV. Provider business mailing address

5424 19TH ST SUITE #300
LUBBOCK TX
79407-2162
US

V. Phone/Fax

Practice location:
  • Phone: 806-795-4391
  • Fax: 806-796-1354
Mailing address:
  • Phone: 806-795-4391
  • Fax: 806-796-1354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberH0596
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberH0596
License Number StateTX

VIII. Authorized Official

Name: MR. ROBERT JERRY MAMLOK
Title or Position: OWNER
Credential: M.D.
Phone: 806-795-4391