Healthcare Provider Details

I. General information

NPI: 1255393252
Provider Name (Legal Business Name): ROBERT J MAMLOK M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2006
Last Update Date: 09/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5424 19TH STREET SUITE #300
LUBBOCK TX
79407-2164
US

IV. Provider business mailing address

5424 19TH STREET SUITE #300
LUBBOCK TX
79407-2164
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 TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License NumberH0596
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: