Basic Information
| Provider Information | |||||||||
| NPI: | 1396816054 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MALICKI | ||||||||
| FirstName: | DENISE | ||||||||
| MiddleName: | MICHELLE | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3020 CHILDRENS WAY | ||||||||
| Address2: | MC5003 | ||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921234223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8583096300 | ||||||||
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| Practice Location | |||||||||
| Address1: | 3020 CHILDRENS WAY | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921234223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8589665944 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/13/2006 | ||||||||
| LastUpdateDate: | 01/26/2017 | ||||||||
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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 | 207ZP0102X | A62107 | CA | N | Allopathic & Osteopathic Physicians | Pathology | Anatomic Pathology & Clinical Pathology | 207ZP0213X | A62107 | CA | Y | Allopathic & Osteopathic Physicians | Pathology | Pediatric Pathology |
ID Information
| ID | Type | State | Issuer | Description | 00A621070 | 05 | CA | MEDICAID |