=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902309776
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SHAN MALIK MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/17/2018
-----------------------------------------------------
Last Update Date | 01/14/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 301 E MAIN ST
-----------------------------------------------------
City | BAY SHORE
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11706-8408
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 631-968-3000
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4705 158TH ST
-----------------------------------------------------
City | FLUSHING
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 11358-3626
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 311776
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------