Basic Information
| Provider Information | |||||||||
| NPI: | 1124303375 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MALLICK | ||||||||
| FirstName: | SOBIAH | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 110 S WOODLAND ST | ||||||||
| Address2: | |||||||||
| City: | WINTER GARDEN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347873546 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079058827 | ||||||||
| FaxNumber: | 4078864282 | ||||||||
| Practice Location | |||||||||
| Address1: | 225 E 7TH ST | ||||||||
| Address2: | |||||||||
| City: | APOPKA | ||||||||
| State: | FL | ||||||||
| PostalCode: | 32703 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079058827 | ||||||||
| FaxNumber: | 4078864282 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/19/2011 | ||||||||
| LastUpdateDate: | 06/29/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207V00000X | ME122099 | FL | Y | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology |
ID Information
| ID | Type | State | Issuer | Description | 015169000 | 05 | FL | MEDICAID |