=====================================================
General NPI Number Information
=====================================================
NPI Number | 1659365211
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MARK MALYAK MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/09/2005
-----------------------------------------------------
Last Update Date | 01/22/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2821 E CEDAR AVE APT 4
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80209-3397
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-781-4198
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7111 E LOWRY BLVD STE 200
-----------------------------------------------------
City | DENVER
-----------------------------------------------------
State | CO
-----------------------------------------------------
Zip | 80230-7360
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 303-394-2828
-----------------------------------------------------
Fax | 303-320-0242
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207RR0500X
-----------------------------------------------------
Taxonomy Name | Rheumatology Physician
-----------------------------------------------------
License Number | 31151
-----------------------------------------------------
License Number State | CO
-----------------------------------------------------