MEDICARE: FATEN MALAK PT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	225100000X	Physical Therapist	12418	FL

General Provider Information

NPI Number	:	1104940220
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	FATEN MALAK PT

Provider Business Mailing Address
First Line	:	5530 LAKE HOWELL ROAD
Second Line	:
City	:	WINTER PARK
State	:	FL
Zip	:	32792-1036
Country	:	US
Telephone Number	:	407-719-1945
Fax Number	:

Provider Business Practice Location Address
First Line	:	5530 LAKE HOWELL RD
Second Line	:
City	:	WINTER PARK
State	:	FL
Zip	:	32792-1036
Country	:	US
Telephone Number	:	407-719-1945
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/16/2007
Last Update Date	:	09/24/2007

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