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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1881787497
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	:	432-336-0700
Fax Number	:	432-336-0704

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	:	432-336-0704

Authorized Official
Title or Position	:	OWNER
Name	:	SUBODH K MALLIK
Credential	:	MD
Telephone Number	:	432-336-0700

Provider Enumeration Date	:	10/02/2006
Last Update Date	:	11/14/2011

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