=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982584645
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MALLICK OBGYN LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/04/2025
-----------------------------------------------------
Last Update Date | 09/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2425 S VOLUSIA AVE STE B1
-----------------------------------------------------
City | ORANGE CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32763-7625
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 386-538-0611
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2425 S VOLUSIA AVE STE B1
-----------------------------------------------------
City | ORANGE CITY
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 32763-7625
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SOBIAH MALLICK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 386-538-0611
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207V00000X
-----------------------------------------------------
Taxonomy Name | Obstetrics & Gynecology Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------