Provider Demographics
NPI:1730445180
Name:MALLACK, ERIC JAMES (MD)
Entity type:Individual
Prefix:
First Name:ERIC
Middle Name:JAMES
Last Name:MALLACK
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 1:6201 GREENLEIGH AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:MIDDLE RIVER
Mailing Address - State:MD
Mailing Address - Zip Code:21220-2004
Mailing Address - Country:US
Mailing Address - Phone:410-933-2704
Mailing Address - Fax:410-500-4266
Practice Address - Street 1:505 E 70TH ST FL 3
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10021
Practice Address - Country:US
Practice Address - Phone:212-746-3278
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-04-10
Last Update Date:2025-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2777332084N0402X
MDD978542084N0402X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0402XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology with Special Qualifications in Child Neurology