Provider Demographics
NPI:1629025804
Name:MALLICK, SHAHLA (MD)
Entity type:Individual
Prefix:DR
First Name:SHAHLA
Middle Name:
Last Name:MALLICK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4685 FOREST AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45212-3397
Mailing Address - Country:US
Mailing Address - Phone:513-853-4721
Mailing Address - Fax:513-852-8525
Practice Address - Street 1:379 DIXMYTH AVE
Practice Address - Street 2:STE N
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45220-2475
Practice Address - Country:US
Practice Address - Phone:513-246-7000
Practice Address - Fax:513-246-7590
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2014-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35070787207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2212028Medicaid
OHP00340572OtherMEDICARE RR
OHG91239Medicare UPIN
OH0869156Medicare PIN
OH2212028Medicaid