Basic Information
| Provider Information | |||||||||
| NPI: | 1912927161 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MALIK | ||||||||
| FirstName: | SHAHID | ||||||||
| MiddleName: | NASIR | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 346 GRAND AVE | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 137902580 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077298156 | ||||||||
| FaxNumber: | 6077633982 | ||||||||
| Practice Location | |||||||||
| Address1: | 33-57 HARRISON ST | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | NY | ||||||||
| PostalCode: | 137902107 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6077636622 | ||||||||
| FaxNumber: | 6077635064 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/20/2006 | ||||||||
| LastUpdateDate: | 10/02/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 242672 | NY | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207R00000X | 0101236201 | VA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 208M00000X | 074862 | GA | Y | Allopathic & Osteopathic Physicians | Hospitalist |
ID Information
| ID | Type | State | Issuer | Description | 02838728 | 05 | NY | MEDICAID |