Provider Demographics
NPI:1124046669
Name:JACKIW MACHACEK, NATALIE M (OD)
Entity Type:Individual
Prefix:DR
First Name:NATALIE
Middle Name:M
Last Name:JACKIW MACHACEK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MS
Other - First Name:NATALIE
Other - Middle Name:
Other - Last Name:JACKIW-SORCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:118 CASS AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043-2204
Mailing Address - Country:US
Mailing Address - Phone:586-464-1479
Mailing Address - Fax:586-464-1480
Practice Address - Street 1:18835 TRADITIONS DR
Practice Address - Street 2:
Practice Address - City:NORTHVILLE
Practice Address - State:MI
Practice Address - Zip Code:48168-9495
Practice Address - Country:US
Practice Address - Phone:248-305-1600
Practice Address - Fax:248-412-5248
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2023-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003822152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U63745Medicare UPIN