Basic Information
| Provider Information | |||||||||
| NPI: | 1073516993 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAMLOK | ||||||||
| FirstName: | VIVIANE | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5865 | ||||||||
| Address2: | |||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794085865 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067432898 | ||||||||
| FaxNumber: | 8067433596 | ||||||||
| Practice Location | |||||||||
| Address1: | 3601 4TH ST | ||||||||
| Address2: | 1A115 | ||||||||
| City: | LUBBOCK | ||||||||
| State: | TX | ||||||||
| PostalCode: | 794300002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8067432155 | ||||||||
| FaxNumber: | 8067432117 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/24/2005 | ||||||||
| LastUpdateDate: | 07/12/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207ZP0101X | H0597 | TX | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology | 207ZP0213X | H0597 | TX | Y | Allopathic & Osteopathic Physicians | Pathology | Pediatric Pathology |
ID Information
| ID | Type | State | Issuer | Description | A120 | 01 | TRIWEST | OTHER | 52453 | 05 | NM | MEDICAID | 82P200 | 01 | TX | BLUE CROSS & BLUE SHIELD | OTHER | 52453 | 01 | NM | PRESBYTERIAN COMMERCIAL | OTHER | 80816Z | 01 | TX | HMO BLUE | OTHER | J6446 | 05 | NM | MEDICAID |