MEDICARE: SUBODH K MALLIK MD PA

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	261QR1300X	Rural Health Clinic/Center

General Provider Information

NPI Number	:	1477847234
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SUBODH K MALLIK MD PA

Provider Business Mailing Address
First Line	:	2071 N MAIN ST
Second Line	:
City	:	FORT STOCKTON
State	:	TX
Zip	:	79735-3041
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2071 N MAIN ST
Second Line	:
City	:	FORT STOCKTON
State	:	TX
Zip	:	79735-3041
Country	:	US
Telephone Number	:	432-336-0700
Fax Number	:

Authorized Official
Title or Position	:	DR./OWNER
Name	:	DR. SUBODH MALLIK
Credential	:
Telephone Number	:	432-336-0700

Provider Enumeration Date	:	06/08/2011
Last Update Date	:	06/08/2011

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