Provider Demographics
NPI:1003993601
Name:MALUEG, KELLY K (OD)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:K
Last Name:MALUEG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1519 ALASKAN WAY S
Mailing Address - Street 2:BASE SEATTLE MEDICAL
Mailing Address - City:SEATTLE
Mailing Address - State:WA
Mailing Address - Zip Code:98134-1102
Mailing Address - Country:US
Mailing Address - Phone:206-217-6432
Mailing Address - Fax:206-217-6636
Practice Address - Street 1:1519 ALASKAN WAY S
Practice Address - Street 2:BASE SEATTLE MEDICAL
Practice Address - City:SEATTLE
Practice Address - State:WA
Practice Address - Zip Code:98134-1102
Practice Address - Country:US
Practice Address - Phone:206-217-6432
Practice Address - Fax:206-217-6636
Is Sole Proprietor?:No
Enumeration Date:2006-11-01
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA3054152W00000X
OR2448152W00000X
ID858152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2016582Medicaid
WA2016582Medicaid
WAAB33542Medicare Oscar/Certification