Basic Information
| Provider Information | |||||||||
| NPI: | 1134104425 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MALIK | ||||||||
| FirstName: | PERVEEN | ||||||||
| MiddleName: | F. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 660599 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752660599 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2145904105 | ||||||||
| FaxNumber: | 2142664162 | ||||||||
| Practice Location | |||||||||
| Address1: | 9202 ELAM RD | ||||||||
| Address2: | SOUTHEAST DALLAS HEALTH CENTER | ||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752174151 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2142661600 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/09/2005 | ||||||||
| LastUpdateDate: | 12/19/2007 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | J2669 | TX | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 139448804 | 05 | TX | MEDICAID | 139448806 | 05 | TX | MEDICAID | 139448811 | 05 | TX | MEDICAID | 139448813 | 05 | TX | MEDICAID | 139448807 | 05 | TX | MEDICAID | 139448810 | 05 | TX | MEDICAID | 139448805 | 05 | TX | MEDICAID | 139448802 | 05 | TX | MEDICAID | 139448801 | 05 | TX | MEDICAID | 139448803 | 05 | TX | MEDICAID | 139448814 | 05 | TX | MEDICAID | 139448816 | 05 | TX | MEDICAID |