Basic Information
Provider Information | |||||||||
NPI: | 1467863530 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MALIK | ||||||||
FirstName: | RAEVA | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 26 QUEEN STREET | ||||||||
Address2: |   | ||||||||
City: | WORCESTER | ||||||||
State: | MA | ||||||||
PostalCode: | 016102478 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5088607914 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 26 QUEEN STREET | ||||||||
Address2: |   | ||||||||
City: | WORCESTER | ||||||||
State: | MA | ||||||||
PostalCode: | 016100161 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5088607800 | ||||||||
FaxNumber: | 5088607925 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/12/2014 | ||||||||
LastUpdateDate: | 11/03/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/03/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 0101263683 | VA | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207R00000X | 6251 | MA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 390200000X |   |   | N |   | Student, Health Care | Student in an Organized Health Care Education/Training Program |   | 207R00000X | 285622 | MA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
No ID Information.