Provider Demographics
NPI:1902882954
Name:MALIK, PRAMOD (MD)
Entity Type:Individual
Prefix:
First Name:PRAMOD
Middle Name:
Last Name:MALIK
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3910 BRIDGE RD STE 101
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-1107
Mailing Address - Country:US
Mailing Address - Phone:757-942-2566
Mailing Address - Fax:855-313-1070
Practice Address - Street 1:3910 BRIDGE RD STE 101
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23435-1107
Practice Address - Country:US
Practice Address - Phone:757-942-2566
Practice Address - Fax:855-313-1070
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2020-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101231641207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010103061Medicaid
VA159847OtherANTEM OF VA
VA159847OtherANTEM OF VA
VA51564OtherOPTIMA
VA559912OtherMAMSI/MDIPA
VA51564OtherOPTIMA
VA159847OtherANTEM OF VA
VA00W183T02Medicare ID - Type Unspecified